Häußermann, C. (2006) Shamanism and biomedical approaches in Nepal –Dualism or Sythesis?
Music Therapy Today
(Online 1st October) Vol.VII (3) 514-622.

 

Shamanism and biomedical approaches in Nepal -Dualism or synthesis?

Carolin Häußermann

FIGURE 1. Jhankris at Gosainkunda; Photo: Mani Lama (postcard)

Prologue by Florian Rubner

Ethnomedicine is an interdisciplinary field of activity and comprises a variety of concepts from natural sciences, social sciences and humanities. Ethnomedicine is concerned with definitions and interpretations of health and illness in different cultures and the resulting culture-specific methods of healing and treatment. The main focus in ethnomedicine is first of all on what is unfamiliar. Other, unfamiliar medical systems are not necessarily structured like our biomedical system. Our concept of anatomy is only one among many other concepts of the human body.

The concept of illness is nothing but a culture-specific definition of suffering, so that therapy may take unfamiliar forms as well.

The Institute of Ethnomedicine - ETHNOMED - offers further simultaneous training to European students with an interest in such an interdisciplinary and intercultural discourse in theory and practice, and whose future professional activities will take place in therapeutical, ethnological or other scientific/academic contexts. Such a solid body of knowledge, experience and (self-) reflection is the best possible basis for therapeutic and counselling skills to unfold.

Objectives of further training for students are to build up sound basic knowledge in ethnomedicine and gain insights into international, ethnomedically relevant fields of discussion. Experienced teachers supervise intercultural encounters and discussions with traditional healers and also convey basic knowledge in other areas of ethnomedicine, for example ethnobotanics, ethnopsychology and ethnotherapy. Practical exercises as well as diagnostic methods and healing procedures are monitored by traditional healers. Competent and experienced scientists provide help in interdisciplinary exchange, interpretation and reflection. Interactive, in-depth interviews are intended to improve perception of behaviour pertinent to one's own and other cultures, reveal cultural and personal patterns and thus make participants aware of socio-cultural aspects in dealing with health, illness and healing. For more information on further simultaneous training for students see www.institut-ethnomed.de or e-mail: studenten(at)institut-ethnomed.de .

This paper on "shamanism and biomedical approaches - dualism or synthesis" was submitted to the Institute of Ethnomedicine - ETHNOMED - as final thesis to conclude the further training programme for students in "ethnomedicine". Carolin Häußermann explores medical pluralism in Nepal at the Tribhuvan University Teaching Hospital (TUTH) in Kathmandu and the Shamanic Studies and Research Centre in Naikap. She points out the origins of this dualism between both systems and possible ways to overcome this historical separation - through dialogue in mutual respect and active studies of interventions as practised by the other side.

Florian Rubner, ethnologist, M.A.

Introduction

Research question

Shamanism and biomedical approaches in Nepal - dualism or synthesis?

I completed the surgery tertial of my practical year as part of my (bio)medical training at the Teaching Hospital of Tribhuvan University, Kathmandu - a unique opportunity to collect a wide range of impressions from health care in Nepal.

Stimulated by the student course at the Institute of Ethnomedicine in Munich and contacts with Mohan Rai, director of the Shamanistic Studies and Research Centre, Naikap, I developed the idea of a field research project on the co-existence of the biomedical system based on western medical training and traditional shamanistic healing traditions in Nepal.

Concept

First I intended to get a more profound understanding of the philosophical principles of shamanistic healing in Nepal and spent a three- week introduction period at the Shamanistic Studies and Research Centre in Naikap. In addition, I had many opportunities to accompany traditional Nepalese healers in their ceremonies throughout my time in Nepal. My main concern was to explore what Western medicine in its definition of illness and health does not consider, or only insufficiently: health and illness in the context of family and village community, and ultimately of cosmology as well.

Working at the Teaching Hospital of Tribhuvan University Kathmandu, I also discovered other perspectives: what was the attitude of Nepalese physicians with Western medical training towards the phenomenon of ,shamanistic healing"? What decided which system suited which patient? What was the basis for a patient or client's decision, and which was the role of financial and ideological criteria, or caste?

My main focus was on a possible synthesis of traditional procedures and modern Western medicine, on areas where both approaches compete, and where they may complement each other in a way that would make sense for Nepal.

I planned to interview physicians and other biomedical health care practitioners on the subject of ,shamanistic healing in Nepal" and to talk with traditional healers about their views on Western medicine, always keeping in mind the limitations of one's own system and the other, the differences between both approaches, and any similarities as well.

This research concept is based on the classical ethnomedical triangle described by Kleinman (1981) who differentiates between disease, illness and sickness. This is a tool to approach the disease/health concept of experts (biomedics, traditional healers) and patients as well as their social context. Kleinman's (1981:104ff) term of EMs (explanatory models) plays an important role in exploring the many healing systems used in Nepal and in clarifying the reasons why patients claim certain types of healing. The various EMs comprise one or all of the following five aspects: etiology, emergence of symptoms, pathophysiology, progress of illness and treatment (Kleinman 1978:87f).

Disease is described as a malfunction or maladaption in the biological or psychological sense (for example, an organic change in the patient), i.e. an explanatory model for illness based on complex mechanisms of development. Disease thus comprises the viewpoint of an expert in the field of health and illness (Kleinman 1978:88).

In 1978, Kleinman still mentions disease as a viewpoint connected with the EM of ,professional practitioners (modern and indigenous)" (1978:88). In the secondary literature (e.g. Pfleiderer 1985; Kristvik 1999), however, this equivalent mention of professional indigenous healers (e.g. illness models of Ayurveda or Traditional Chinese Medicine) is often left out, thus reducing disease to the perspective of biomedicine and therefore the scientifically based component. This might give the impression that the so-called biomedicine is an objective categorization of illness symptoms; but it must be pointed out in this context that even biomedicine is not free of its own cultural conditioning, and we should keep this thought in mind.

"Conversely, biomedicine does not contain culture-free clinical realities and EMs." (Kleinman, 1978:91)

Illness, on the other hand, according to Kleinman expresses the experience of a patient with deviations from a state he himself defines as healthy, and the significance he, his family and his environment give to these deviations, as well as their own personal EM on their generation (ibid 1978:88). ,Illness is the shaping of disease into behaviour and experience", as Kleinman (1981:72) comments on his definition. In addition, illness is sometimes used by therapists concerned with psychosomatic problems. Also healers who work with cosmological causes of illness and being ill, seem to use socialogical and psychicological explanatory models in the sense of the EM illness quite convincingly (ibid 1978:88).

Sickness is the term comprising these both components, the entire coin with the two sides called disease and illness, so to speak. Sickness includes technical as well as personal, socialized explanatory models for illness or being ill, in the sense of absence of health.

The differentiation between disease and illness demands different approaches. Kleinman says in his concept that disease may be handled by curing, that is a removal of physical symptoms, whereas illness may be handled by healing, i.e. a holistic approach.

Kleinman (1981:38) also uses the term clinical reality, which describes the views, attitudes and standards of a social group with regard to illness and healing. This definition does not differentiate between a group with biomedical or traditional shamnistic views.

"Health care outcomes (compliance, satisfaction, etc.) are directly related to the degree of cognitive disparity between patient and practitioner EMs and to the effectiveness of clinical communication." (Kleinman 1981:114)

Only when healer and patient are aware of their different explanatory models, when they try to see the impairment of health at the same level of meaning and at least to approximate their explanatory models, can they achieve an increasingly positive, healing effect, but with one qualification: obviously, explanatory models of individual patients cannot be considered as static - they change with time and experience. A patient may also have several EMs at the same time (Kristvik 1999:40). In my opinion the art therefore lies in looking for approximations of changing explanatory models in the healer-patient interview.

"Constructing illness from disease is a central function of health care systems (a coping function) and the first stage of healing" is how Kleinman (1981:72) formulates the objective of a healer's activities.

Implementation

The Kathmandu valley was repeatedly chosen for ethnomedical studies on the medical pluralism existing here. For me, too, this was the place to accompany shamans and biomedical physicians in their work.

Methods

The methods used in this field research were accompanying observation, experience analysis, interviews and chance talks. Later, after my return, I added literature research and evaluation.

FIGURE 2. Entrance to Universtiy Hospital

Biomedicine at the Tribhuvan University Teching Hospital, Kathmandu

The Institute of Medicine at Tribhuvan University Kathmandu, founded in 1972, today trains medical staff of various professional fields. ,To prepare medical graduates who will have the skill, knowledge and attitude to work in the environment that exists there", this is how Gartoulla (1998:36) describes the objectives of student training in medicine in the undergraduate programme at Tribhuvan University. Practical and theoretical teaching units in medical sociology, medical anthropology and psychology were introduced in the curriculum.

This is where I spent four months in surgery as part of my practical year and where I learned more about projects and research approaches in medical anthropology in Nepal from teachers, physicians and students.

Download Video (Surround view from the rooftop of the Shamanistic Studies and Research Centre, Naikap)
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Shamanism: the Shamanistic Studies and Research Centre, Naikap

In 1988 Mohan Rai established the Shamanistic Studies and Research Centre, Naikap, to preserve the knowledge of Nepali shamans and also to acquaint interested foreigners from Europe, U.S., Canada and Australia with shamnistic philosophy and the healing techniques involved (see brochure M. Rai):

"Shamans who teach at Shamanistic Studies and Research Centre als carefully selected from Himalayan mountain tribes including Tamang, Rai, Sherpa, Gurung and others, both for their reputations as powerful healers and for their ability to transmit their knowledge to foreign students."

I spent my first three weeks in Nepal at the Shamanistic Studies and Research Centre, Naikap, to gain insights into the cosmology of Nepali shamans and to learn about their models of illness, their methods of diagnosis and therapy in theory and practice. I attended numerous ceremonies, mainly in the evenings.

My closest contacts were with two female shamans, one of the group of Kiranti-Rai (1), the other of the Tamang, so that my experience with shaman healing is mainly from the repertoire of the shamans of these ethnic groups, even if some basic procedures in diagnosis and therapy are common to most Nepali shamans.

Nepal - Research at the foot of the Himalayas

General regional studies

FIGURE 3. Annapurna- Himalaya

Nepal measures 800 km from northwest to southeast with an average width of only 200 km (Donner 1990:10) and is located between the huge states of China in the north and India in the south. Currently it is subdivided into five development regions, 14 zones and 75 districts (Gartoulla 1998:3). The country comprises highly different zones of vegetation with an unbelievable variety of fauna and flora, starting with the subtropical southern Terai region, branching out from the Ganges plain, to the hills (between 610 m and 4877 m above sea-level) and up to the snow-covered Himalaya peaks in the north (mountain area between 4877 m and 8839 m above sea-level) (ibid:8). Its inhabitants are just as varied: about 75 different ethnic groups speak ca. 50 different languages (ibid:5). Only 58 % of the entire population have a command of Nepali as the lingua franca (ibid:5). The caste system in Nepal with a majority of Hindus (90 %) still dominates many areas of daily life. Other significant influences are Buddhism (5 %) (ibid:6) and far older traditions, in part animistic, depending on the respective ethnic group.

Social and health care situation

According to the WHO Nepal is among the poorest and least developed nations of the world. The economic basis is agriculture, mainly in the form of subsistence economy, comprising over 90 % of the working population (Donner 1990:100). Industrial development is still in its early stages. Tourism was the most important source of foreign exchange before increasing armed riots in recent years resulted in a considerable fall in the number of tourists and income from foreign exchange. More and more workers migrate to the Gulf states or India and support their families back in Nepal (Benedikter 2003:165; Graner 2005).

Per capita income in Nepal is among the lowest of all south asian states. UN statistics indicate US $ 235 as annual per capita income, and 42.5 % of the population in Nepal as living in absolute poverty (Gartoulla 1998:12).

Education levels are low with a literacy rate of only 54 %. In 2001, about 80 % of boys finished primary school, but only 40 % of girls (Benedikter 2003:209).

A look at the health sector reveals why the WHO counts Nepal amongst the least developed nations world-wide: the Nepal Human Development Report 2004 speaks of per capita expenditure for health of US $ 2.0 per year, stagnating at this level for years.

Live expectancy at birth is currently 62.2 years (2). Mother and infant mortality are high in Nepal (Tiwari 2005). Most frequent diseases are skin diseases, acute respiratory infections and diarrhea, followed by intestinal worm infestations. Diarrhea is a tremendous and widely spread problem among infants in Nepal and is reflected in the high mortality rates of children under five (ibid 2005).(3)

There is no even distribution of medical facilities due to the geography; distant rural areas (see Figure 4) are clearly disadvantaged (Haddix McKay 2002). Only 29 % of the poor have access to a health care facility in less than 30 minutes (WHO 2004). Moreover, health care facilities in rural areas are limited in what they can do: lack of medical-technical equipment, drugs and personnel are the main problems for inhabitants of rural areas looking for help in medical facilities (Haddix McKay 2002; WHO 2004). Benedikter (2003:160) points out that in the rural areas in Nepal with about 83 % of the population there is only one physician per 57.000 inhabitants.

FIGURE 4. Geographical conditions

For more than 10 years now, the so-called Maoists have been waging guerilla warfare against the Nepali army and the king as the representative of monarchy; as a consequence, economic, social and health-related systems have seen a dramatic deterioration: experts believe that about 50 % of all health care facilities in the country have either not enough medical personnel or none at all (WHO 2004). The health workers on site are increasingly threatened or intimidated by Maoists and government troups alike. Bans on driving and road blocks delay or impede delivery of medical supplies and equipment (Benedikter 2003:240).

In addition to its traditional problems the country has to cope with a growing number of internal refugees, uncontrolled growth of the capital Kathmandu (ibid:165), organized crime (Dacoits) - mainly in the border area with India (CIJ 2004)-, increasing drug problems and domestic violence (Benedikter 2003:200), states of emergency, general strikes, massive violations of human rights, e.g. disappearances, kidnapping, forced recruting of child soldiers, torture and killing between both sides involved in the civil war (Benedikter 2003:239).

Last March (2006), the political situation in Nepal took another turn for the worse when the maoists ended their unilateral truce after the king had announced elections for February without consulting the political parties. The major parties boycotted the elections and organized protests in Kathmandu that soon expanded nation-wide, bringing more and more people out into the streets despite curfews who expressed their dissatisfaction with the intolerable situation. After mass demonstrations leaving many dead or injured, and adverse reactions from police and armed forces, the king finally had to submit to pressure and returned the executive powers to the parties.

The situation seems clearly improved now, although by no means stable, but some important progress has been achieved: the king's powers are much curtailed, maoists form part fo the government, and constitutional elections have been scheduled for next year.

Concept of illness in Nepal

"Medical belief systems are sets of premises and ideas which enable people to organize their perceptions and experinces of medical events and to organize their interventions for affecting and controlling these events. In a nutshell, they are ways of defining problems and generating solutions to these problems.' (Young 1983:1205)

There is not one single concept of illness in Nepal. Explanatory models of different individuals and groups on the generation of illness are influenced by a variety of factors like income, caste, age, religion, but mostly by social class, level of education, by life in the city, especially the metropolis Kathmandu with its strong western influences, or by life in the country and in remote regions.

Advice by family and friends as well as personal experience with illness also play an important role.

I found that a biomedical concept of illness, based e.g. on the theory of germs, was spread among the staff of the teaching hospital, but also among a majority of my neighbors in the Baluwatar sector of Kathmandu.

Gartoulla (1998), Kristvik (1999) and Subedi (2001) sum up the various traditional explanations for illness in different systems which, however, correspond to each other in principle. In my description of traditional explanatory models for illness I shall follow the system by Subedi who differentiates between individual causes, natural world, social world and supernatural world (Subedi 2001:35). In the time I spent in Nepal I found the following causes for illness within traditional explanatory models:

Individual causes

Individual causes cover illnesses which der patient has mainly caused himself. They are seen as the consequence of wrong eating habits or changes in diet, or wrong behavior that impairs health (Subedi 2001:35).

,Illness is increasingly blamed on ,not taking care' of one's diet, clothing, hygiene, sexual behavior and physical exercise. Illness is therefore an evidence of such carelessness, and the sufferer feels guilty for causing it. For the prevention and cure of these health problems the victims change their food habits and other behaviors." (ibid:35)

In my experience this explanatory model for illness also plays an important role with patients at the university hospital. At the out-patient department patients and their relatives very often asked whether wrong or recently changed diet had caused a patient's illness.

Natural world

Unfavorable constellation of planets (Graha bigrayo)

This concept ist strongly influenced by hinduism and sees the constellation of planets at an individual's birth or in certain times of his life as a cause of illness or misfortune in general, e.g. family conflicts or financial problems. From this perspective planets affect the big and small things in man's life and determine success or failure. Many Nepalis consult astrologers to determine lucky dates for weddings or other important life events.

Illness due to planet influences, so-called khadko, must be repaired by shamans, e.g. through the khadco kattne ritual, a cutting of the threads of destiny. This ritual is performed for individuals who have experienced a period of extreme misfortune, loss of property, loss of beloved ones, depression or serious illness.

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Imbalance of hot and cold

The concept of hot and cold known to many Europeans from the principles of Traditional Chinese Medicine (TCM) sorts food, but also physical symptoms of illness, times of the day and seasons, climatic influences and human character traits and constitution into the two opposites of hot and cold. The idea is that a balance of hot and cold must be maintained, or recovered in the case of illness, in order to achieve health.

Therapeutic principles are to cool conditions of too much heat, and to treat illnesses caused by too much cold with warmth, for example with types of food considered hot, whereby the system of hot and cold does not necessarily refer to the temperature of the food. On the other hand Nepalis also know states with too much heat that are cured with hot food. Stone (1976) listed as hot (in Nepalese: gharmi) food meat, eggs, milk and tea. Cold (in Nepalese: chiso) are yoghurt, cucumber or bananas (4). The belief is that additional warmth will finally achieve a maximum of warmth in the body as a precondition for a slow reduction of excessive warmth until a balanced state is achieved that means physical well-being.

A case in point is that of a Nepali acquaintance of mine. He was in bed with chickenpox, shaking with chills and covered with pustules, and his aunt who fed the family ,treated' him with a diet of rice and hot milk.

Social world

Bokshi

Bokshi or witch is the name given to a woman (less frequently a man) from the patient's social world who practises magic against harm. The most frequent reasons quoted for harm befalling individuals are envy or some grudge, or the rage of the Boskis and a previous argument. The witches receive their skills from older witches who train them. Childless elderly women are often assumed to practise witchcraft, so that women of this type generally are suspicious.

Gartoulla (1998) describes how Bokshis may harm people: they produce a small figure representing the victim and pronounce magic spells, or they actively mix bewitched substances into a victim's food. They keep such substances - human hair, finger and toe nails, animal claws or bone fragments - in small bundles.

Bokshis are believed to harm or cause illness through the evil eye. A Bokshi is also believed to be able to induce certain gods (e.g. Devis) or other supernatural powers (Masaans, Bhutas) to harm a victim or to send dangerous animals like snakes or tigers to kill him or her. They say witches can shoot bewitched spiritual arrows that cause illness, or witches come to their victims at night and drink their blood, so that they get weaker and weaker (Gartoulla 1998:131). (5)

Shamans in Naikap claimed to be able to determine the identity of a witch who had harmed a patient. However they would never mention names. This is also the experience of Peters (1979) and Sidky (2000).

Evil Eye

The Evil Eye, also known from other cultures like Turkey (6), is a common concept according to which illness may be caused by a person's look. Envy is a frequent reason, and in Nepal the Evil Eye is closely related to the Bokshis' magic. However, the Evil Eye is rather seen as an unwise and unintentional envious reaction and not, as with witches, a deliberate deed in order to make someone ill.

Many Nepalis believe that children are highly vulnerable to the Evil Eye, and they paint babies' and infants' eyes with kayal to protect them.

Supernatural causes

Acute and/or serious health problems in particular are seen as indications of supernatural causes. If diseases take sudden turns for the worse or lead to loss of mental abilities, people also assume supernatural causes, an angry god or a neglected ancestor spirit.

Attacks by gods

  • Gods in general, e.g. Jungali, Nagas, Devis

Jungali, the goddess of the forest, has a decisive role in the Kiranti-Rai concept of illness. She is the mistress of nature, and wrong behavior or lack of respect of nature may cause Jungali to attack. Mohan Rai in Naikap desribed how victims will suffer strong and sudden headaches, get mad or get many further health problems.

A cure requires sacrifices to Jungali - monitored by the shaman who speaks a Jungali mantra but performed by the patient himself, his physical condition permitting. This ceremony always takes place in the open.

Nagas are snake gods and live in all forms of water. Water contamination makes them angry.

Gartoulla (1998) gives an exact description of illnesses that may be caused by Sitalamai, goddess of the pox, and of what must be done to cure such patients.

Stone (1976) underlines that Devis (goddesses) may also cause illness, e.g. Akash Devi whose shadow may fall upon children and thus harm them.

  • Kuladeva

Kuladevas are ancestor spirits and highly significant elements of the health concept of the ethnic group of Kiranti-Rai. If these spirits are not sufficiently respected, if rituals for deceased family members are not performed or not with care, an angry Kuladeva may make a family member ill in order to point out any neglect of ancestors.

In contrast to evil spirits, the gods and ancestor spirits may cause illness out of anger about neglect, i.e. a failure on the part fo the victim or a relative; but in contrast to Bhutas they do not attack without provocation, nor are they summoned by witches.

Attacks by evil spirits

All evil spirits have in common that they attack innocent victims or may be summoned by Bokshis to harm someone. These attacks against innocent persons are due to the fact that the evil spirits are hungry and try to still their hunger.They are believed to slowly suck life out their victims. Therefore the harmed individual is a victim of evil spirits and not guilty of his illness, as he would be e.g. in case of taboo violation or neglect of ancestor spirits.

The Nepali know many different kinds of evil spirits. The following descriptions of evil spirits come from shamans in Naikap:

  • Bhuta

Bhutas (7) are divided into subcategories of which I know 26. They are all spirits of deceased persons who died an early or unnatural death, through accidents, suicide or at giving birth. At certain times of a day (8) the danger of Bhuta attacks is higher, and Bhutas always attack the weakest member of a social group, those who had an unfavorable planet constellation at birth or are already weakened by illness.

  • Pret

Pret is the invisible spirit of a dead person (Gartoulla 1998:129). Mohan Rai sees the Pret as a ghost ,who acts evil, restless and who makes others unhappy and unrest. As a matter of fact pret is another word for bhuta".

  • Masaan

Masaans also have several subtypes and stand between men and gods in the shaman cosmology. In their lifetime they were respected individuals, e.g. powerful shamans or lamas who died an unnatural death. Powerful as they were in life, they have much influence after death as well. They can do much harm to humans, but some shamans evoke them as helpers in their spiritual journeys and in healing rituals.

Masaans (9) are believed to prefer to dwell near Ghats or on cemetaries where they are visited by powerful shamans (Müller-Ebeling 2000).

  • Bayu

The Bayu is a spirit of wind and air, and capable of triggering big catastrophies like tsunamis if not treated with sufficient respect as I was told in Naikap.

Stone (1983:976) describes the Bayu as the spirit of a person after unnatural death who attacks his own relatives and makes them ill. Only after ritual acceptance of the Bayu into the circle of ancestor spirits will he stop molesting his living relatives and causing illness.

  • Lagu

Gartoulla (1998), Peters (1979) and Stone (1976) found in their field research that the term ,Lagu" is frequently used as a general term for all evil spirits, i.e. Bhuta, Pret, Masaan etc. Mohan Rai comments as follows:

"Lagu is a common word in Nepali. For example, if someone is attacked by evil spirits or devis and devas, but mostly evil spirits.(...) Actually, Lagu means to become certainly and immediately sick. This can be mostly in the morning, by midday and evening. (...) This we call Lagu/Lagan."

Loss of soul

The soul of an individual may be lost in various ways. In several interviews in Naikap I heard that children may lose their soul easily. For example, waking up with a start may cause loss of the soul, since the soul leaves the body in sleep and may not have enough time to return to the body. But shock situations in daily life or attacks e.g. by stray dogs may cause the soul to be lost. On cemetaries 10) or near the Ghats, the places where Hindus burn their dead, the soul may also be lost. Some people even told me it might be harmful to be patted on the right shoulder from behind. Signs for loss of soul may be absent look(11) and physical weakness, in children watery diarhhea, glassy eyes, restless sleep and continuous weeping. A ceremony to recover the soul is the required therapy to be performed by an experienced shaman.

Here I would like to underline again that the above concepts on generation of illness - including the biomedical explanatory model, which was not described in detail - must not be seen as categorically separate. Most Nepalese accept a combination of several explanatory models or change their viewpoint on the cause of an illness with time or, independent of their own illness, through new impressions and experiences. So there is no static or systematic basis for these concepts. Medical pluralism in Nepal on the one hand corresponds to an individual pluralism of explanatory models for illness on the other.

III. Healing systems

1.) Biomedicine

"'Medicine', to the western mind, is based on the notion that science, with its methodology of research and experimentation, is potentially capable of combatting any sickness and curing any disease", according to Blustain (1976:83).

The national health system in Nepal, which developed gradually only after the borders opened in 1951 and only with substantial foreign support, introduced decentralized integrated services in the form of so-called Rural Health Posts in 1960. 5-year plans on national health addressed a variety of prevention areas and diseases, e.g. programmes to fight malaria, pox, tuberculosis and leprosy, birth control projects and mother-infant care, as well as an extended programme of basic immunization (Dixit 1999; Gartoulla 1998).

Starting in the 1970s, there was a gradual shift away from curative towards preventive programmes. After the WHO declaration of Alma Ata, Nepal introduces the principle of Primary Health Care (PHC) (12).

"What has been accepted even by the authorities is that the health services provided by the government reach no more than 10 - 15 % of the population and that even after a great deal of resources put in and effort expended." (Dixit 1999:38)
FIGURE 5. Directions to University Hospital facilities

In figures: in 2001, there were 1259 physicians in public hospitals and surgeries in the entire country, that is one physician for 19.695 inhabitants. In 2004 the Ministry of Health registered 5 specialized central hospitals, 1 regional hospital, 1 subregional clinic, 11 zonal clinics and 62 district hospitals (Tiwari 2005) plus several small Health Offices and health posts or stations, the latter poorly equipped (Haddix McKay 2002).

Although jobs in remote areas are better paid, it is hard to find health care employees who are willing to take these jobs. A combination of higher wages and free further education programmes (13) had some success (WHO 2004). For a survey of the structure of the health care system in Nepal see Appendix.

Medical personnel

Physicians

Nepali physicians in their majority are not interested in jobs in rural areas. According to Benedikter (2003:160) 60 % of all physicians in Nepal work in the capital Kathmandu. Consequently, the rural areas have one physician for approximately 57.000 inhabitants (ibid 2003:160)!

A surgeon at the TUTH told me that even the offer of double salary for a position in a rural area - a programme of the Nepalese Ministry of Health in order to make rural areas more attractive to physicians - was not successful, so that the programme was stopped.

Physicians repeatedly told me that jobs in rural areas are seen as dead end for a medical career. Poor equipment and insufficient supplies of drugs at the health facilities in rural areas are further reasons for physicians to see such positions as unattractive (Gartoulla 1998:57 and 73ff).

From discussions with medical students at the TUTH I learned that the most-sought after jobs for graduates of medical schools in Nepal are in the United States or at least in Europe, and that they are making tremendous efforts to get them. Among medical graduates in Nepal the brain drain is huge (Dixit 1999:183).

Those physicians who work in Nepal in public clinics try to get jobs at private hospitals in addition which creates much additional income. But this requires to find jobs near larger towns or cities where private and public health care facilities are nearby and such double employment is possible.

Nurses

Training of nurses started in 1987 and follows a so-called ,community orientation" (Dixit 1999:165) in preparation not only for nursing in city clinics and nursing homes but also for positions in rural areas. In 1999 Dixit wrote that 280 nurses finish their training each year (ibid). The situation improved when several other nursing campuses opened, some of them with private teaching. In 2005 Nepal had 6.216 nurses, and a total of 6.654 hospital beds, taking the public and the private sectors together. These figures clearly indicate a drastic lack of health care personnel compared to a population of 23.151.423 (Tiwari 2005).

Health assistants /health workers

Most of these health workers receive short training programmes. Their tasks at Health Posts are mainly curative, e.g. prescription of drugs, and some preventive aspects, e.g. vaccinations (Gartoulla 1998:57).

Some workers at community level have received specific training as Community Health Leaders in order to recognize certain diseases like diarrhea, leprosy or tuberculosis and to prepare oral rehydration solution, nun chini pani.

The Village Health Workers are mainly employed for prevention, e.g. building latrines etc. (ibid:20).

However, in remote regions of Nepal the role of health workers is often comparable to that of physicians. They have to assume many of their responsibilities since physicians are so rare.

Peons

"This is usually a local person. His training is not from far away, his skills are acquired on the spot. The peon distributes the medicine prescribed by the person in charge, he gives injections and changes dressings.(...) The peon tends to be the one who gives the system stability and the one who does much of the work and has patient contact. He is the one who stays in place." (Kristvik 1999:80ff)

Peons quite often are the only staff patients will see at Healths Posts or Sub-Health Posts. Although they are only intended to help out, often they hand drugs out to patients, even without checking with those in charge (Haddix McKay 2002).

Diagnosis procedures

Biomedicine uses anamnestic, clinical, laboratory-chemical and apparative procedures for diagnosis. Anamnesis is a patient interview on his current health problems, covering pain symptoms, previous illness, allergies or incompatibilities and drug intake. First the patient answers questions on vegetative factors like sleep, appetite, thirst, weight, stool and urination or consumption of drugs (also alcohol and tabacco). A comprehensive anamnesis also addresses aspects of a patient's social background, i.e. job, marital status, leisure activities, illness and causes of death among near relations, in order to discover heredited problems. Women are asked about menstrual cycle, births and post-menopausal problems where applicable. Clinical aspects comprise physical examination. Body parts where the patient indicates complaints are examined in more detail. Medical-therapeutical devices are stethoscope, reflex hammer, light, spatula etc. Laboratory-chemical diagnostics are performed where applicable through analysis of a patient's blood, urine, stool or sputum samples.(14) Apparative examinations comprise non-invasive and invasive interventions. Non-invasive diagnostic interventions are ultra-sound, X-ray, CT and MRT. Endoscopies, punctures or biopsies are invasive.

Therapy

Biomedical therapies are divided into causal and symptomatic, but also curative and palliative interventions. Causal therapy covers the elimination of the cause of an illness, e.g. surgical appendix removal in appendicitis. Symptomatic therapies remove only the complaints and effects of an illness as indicated by the patient but not the original cause, e.g. pain killers for toothache. Curative therapy is defined as a complete and frequently surgical removal of the cause of an illness and the return of the patient to a state of health. Palliative therapy is mainly mentioned in the context of oncology with tumor patients with unfavorable prognosis and covers maximum symptom control with the intention to improve patients' quality of life. In addition, biomedicine differentiates between drug therapies, interventional and surgical therapies.

Treatment costs

Costs for treatment in biomedicine vary considerably: they depend on chosen diagnostic and therapeutic procedures, but also on the respective health care system and the underlying health philosophy and in addition on the status of the clinic in question (public, NGO or private).

Nepal does not know obligatory health insurance so that patients and their families have to pay for each single (bio)medical service immediately.(15) Relatives of a patient even have to buy suture material for wounds, cannula, syringes and sodium chloride solution from a drug store affiliated to the hospital, after the physician has made a list of the required materials and drugs. Even before a patient meets the physician he has to pay for the consultation at the hospital ,counter". Emergencies receive medical treatment while another person accompanying the patient has to handle payments.

The Western Regional Hospital (WRH) in Pokhara has a price list for surgical operations as I learned during my stay there in 2003; they differentiate between major (large or long operations), minor (smaller) and foreigners, and these three main groups are subdivided further.

Most public hospitals and many of those managed by foreign NGOs have a social fund to cover treatment costs for poor patients in part or entirely. However, this often requires complex petitions in order to substantiate such claims.

2.) Shamanism

Maile the shaman sat down in front of the altar while an assistant walked around collecting all necessary utensils. Incense was burning in a bowl of hot coals. The shaman blessed the altar with some rice, her assistant sprinkled rice on the heads of those present. Maile started to drum herself into trance after she pulled her malas - rudraksha, ritha and bell mala - across her shoulders. We sat there for a long time and listened to the drums, Maile's singing and the words the assistant called out to her. One of those present also went into a trance and also started to shake. At one time Maile's assistant gestured to me to sit down beside the shaman. The questioning of my ancestors was to begin. I received a phurba in my hands and closed my eyes. The helper whispered I should try and sit relaxed although this was not easy in view of my excitement. I tried to imagine my ancestors and started to visualize Jungali and Bhairab. Maile danced around me with her drum, I closed my eyes and soon had a feeling of sitting inside the drum myself. Everything was vibrating, and I started getting goose- pimples. Tremendous warmth rose inside me. Then all of a sudden something humid was sprinkled over me, and the feeling on my skin alternated between hot and cold. Images of respect and trust appeared before my inner eye repeatedly. This was what I wanted to show to the people who had accepted me here. Maile gradually slowed down her drumming and finally stopped. I opened my eyes, got up, threw three hands full of rice towards the altar and again took a seat along the outer wall. The helper gave some chang (rice beer) to all present and told us to sip once and to spread the rest on our heads. Then Maile's helper translated what the shaman had heard in her trance.

FIGURE 6. Traditional healer Parvati performing a healing ritual

"A shaman is a person who at his will can enter into a non-ordinary psychic state (in which he either has his soul undertake a journey to the spirit world or he becomes possessed by a spirit) in order to make contact with the spirit world on behalf of members of his community",

as Reinhard (1976:16) wrote in the introduction to "Spirit Possession in the Nepal Himalaya", an anthology on the phenomenon of Nepali shamanism.

A large variety of subcategories of shamans has been described to exist in Nepal. These are e.g.: Dhami, Jhankri (16) (Gartoulla 1998; Hitchcock 1976), Yeba, Yema, Samba, Mangba (17) (Jones 1976:31ff), Ojha, Fedangwa (18), Bijuwa, Baidang, Jharphukey (Gartoulla 1998:19ff) and Phombo (Sidky 2000:47).

In the following I shall mainly refer to Dhami and Jhankri and not go into detail on the other types of shamans in Nepal to avoid confusion. Dhami and Jhankri are the terms I have used for the shamans I accompanied.

Dhami or Jhankri

These two terms are not used consistently in literature: Stone (1976) translates Dhami as medium or psychic person while she uses the term Jhankri for shamans of the Tamang or rather unspecifically as a synonym for shamans.

Personally she mostly speaks of Janne Manche (people who know), but she underlines that they do not undertake spiritual journeys but are possessed by gods and spirits. Gartoulla (1998:123) describes the Dhamis as shamans from the Brahman caste, Jasi and Chhetri. They evoked their ancestor spirits (Kuladevas). Jhankris, in contrast, who do not belong to that caste, cooperated with the Masaans or with Shikari, a god described as a hunter. Unlike the Dhamis, they preferred wide white robes for their ceremonies (ibid:19ff). Kristvik (1999) finds in her field research in east Nepal that people in Bhojpur use Dhami as a synonym for Jhankri. Mohan Rai told me: ,Dhami Jhankri is general Nepali."

The Jhankris I met use Jharphuk and trance and contact supernatural powers for diagnosis and healing.(19)

There is no deliberate decision to become a shaman in most cases. The shamans I asked told me that they had become shamans in different ways: one shaman describes an introduction through Ban-Jhankri, the original shaman, who he said introduced him to all secrets of the shaman cosmos when he was a child. After this shaman died, a ritual revealed that his youngest son who until then had shown no interest in shamanism would continue his father's healing tradition - even the shamans selected for his training were named in the ceremony. The son was chosen by his father's spirit in the ritual, which became visible in the son's shivering and the fact that his father's ritual objects were used for himself.

Another shaman has followed in the family tradition and is part of a long succession of shamans in his clan. All shamans interviewed spoke of initiation experiences that directed them towards shamnistic healing - as adolescents in most cases.

The work of a Nepali shaman is not a regular job or source of main income. Most shamans are farmers or have other jobs and assume the healing function whenever required by patients or their relatives.

Shamans appear to see it as their duty to help those who contact them with a wide range of complaints. They endure all-night healing rituals, accept interruptions of their own work and even personal health risks. Being a shaman means not only to ,do one's job" but a serious vocation where the knowledge of one's teachers has to be applied with respect. This is the impression I gathered during my stay with the shamans in Naikap.

Other terms for the shamans in Nepal have to be defined:

  • Ojha

Ojha is a Jhankri who is an expert for particularly severe or chronic illness. A Jhankri contacted by such a patient asks the Ojha for help if he has failed to heal the patient (Gartoulla 1998:21).

  • Fedangwa, Bijuwa

Fedangwa is the name given to their shaman by the ethnic group of Limbu, according to Mohan Rai (see Gartoulla 1998:21). Bijuwa is the Rai name (ibid:21). Mohan Rai added that apart from Bijuwa, the Kiranti-Rai also use the names Noksung and Mangpa. These Fedangwas sometimes use brass bowls instead of drums to reach trance. For their rituals they wear long white robes and malas (chains) across the chest (Gartoulla 1998:21).

  • Baidang or Jharphukey

He does not enter the trance state and uses only Jharpuk as a method of diagnosis (Gartoulla 1998:21; Blustain 1976). Mohan Rai told me that the Baidang uses neither drums nor the Phurba (ceremonial or spiritual dagger).

Diagnostic procedure

"The shaman uses trance and non-trance divination techniques to learn the nature of a patient's illness and its cause, the whereabouts of lost objects, the identity of a their or source of jealous thoughts",

according to Mohan Rai's short description of the Nepali shamans' diagnostic methods in a brochure.

The shamans I was allowed to accompany in Nepal employ pulse diagnosis (nadi herne), rice diagnosis (ankat herne), ginger diagnosis, water diagnosis or mala diagnosis. An even or uneven number of pearls being counted in a randomly chosen section of the mala provides the answer to the question asked before on the patient's illness, i.e. either "yes" or "no". The same applies to ginger and rice diagnosis which are also employed like an oracle, or Jokhana. In addition, the shamans in Naikap use bamboo staffs as spiritual binoculars, but also drums and trance journeys to the three worlds of the shamanistic cosmos in order to ask various helpers for indications of the cause of illness and possible therapy. (20)

FIGURE 7. searching the cause of the patient's illness

Therapy

A shaman's healing procedure may last a few minutes only in some cases or comprise extended and costly all-night rituals that may have to be repeated or continued over several days. Jharpuk is the general term for all short healing procedures that are performed with spoken mantras and removal of negative influences immediately after the symptoms occur (21).

Medicinal herbs or certain diets are often prescribed and regularly sought for by patients and families. Amulets are produced by the shaman himself and contain either a powerful object (animal claw, medicinal herb etc.) or a protective mantra written on paper. Accordingly, the amulets carried around the neck protect the bearer from negative influences.

An example of a prolonged ritual is the khadco kattne, the cutting of the lines of fate, to be performed in case of negative planet influence and sometimes accompanied by animal sacrifice. (22)

Download ritual video
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Supernatural causes of illness mostly demand appeasement, which the patient may achieve himself in the form of regular pujas for Kuladevas or other deities, if these are angry because of a lack of attention. The shaman on the other hand has to incur the good will of the evil spirits with rituals involving food.(23)

Eigner sums up her experience with shamanistic healing in Nepal as follows:

"The superficial structure of shamanistic healing methods is varied. But deeper down they basically consists of the same elements: connection of therapeutic procedures with cosmic forces, reduction of the damaging burden for the patient, a redefinition of the suffering experienced through a specific symbolic system and a manipulation of symbols through which a transition is made from the state of illness to that of health." (Eigner 1998:69)

Treatment costs

The costs of consulting a Nepalese shaman are generally lower compared with biomedicine. Small healing procedures are free sometimes. In many cases a patient pays a shaman according to his own judgement or financial possibilities, the gift being either money or natural produce. For larger and more extensive ceremonies the shaman describes to the patient or his family exactly what is required, e.g. a sacrificial animal, chang, rice and so on. In some ceremonies all present are guests of the patient's family , which may be expensive depending on the length of the ceremony and the number of participants.

One of the Phombos, the Jirel shamans in east Nepal, summarizes:

"Phombos are like doctors, we treat people who are suffering from spirits, in other words, those who are stricken with illnesses that are of a supernatural origin. We do it with mantras, herbal medicine, and the help of our own spirits." (Sidky 2000:46f)

3.) Other healing traditions

Religious healers

"A priest is usually part of a larger religious establishment, is more concerned with the conduct of group rituals and derives his relation with supernatural powers by virtue of his office within [an ecclesiastical establishment]. The shaman, to the contrary, is usually an individual practitioner, and his contact to the supernatural world is personal and immediate." (Murphy 1989:203, quoted in Sidky 2000:41)

Lama, Hindu priest, Jyotishi

Lamas, Buddhist scholars, are consulted specifically in Bhuddist communities. They perform prayer ceremonies for sick persons (Haddix McKay 2002), which is called ceremonial healing (Dietrich 1996).

Hindu priests and Jyotishi (astrologers) are often asked for a diagnosis. They calculate the influence of planets on a patient. The Hindu priests then perform the Puja required for recovery, and therefore are in close contact with the astrologers. Hindu priests are often able to calculate planet influences themselves.

FIGURE 8. Puja place at a Shiva Lingam

Unani

Unani medicine has its roots in Galen's humoral pathology. It developed in the Islamic sphere and reached Nepal via India (traveliteindia). The Unani practitioners are called Hakim in India and Jaanne in Nepal, according to Blustain (Blustain 1976:96).

Ayurveda

Ayurveda, the knowledge of long life, is an old Hindu tradition of healing that reached Nepal from India. It is based on the principle of the Tridoshas: Vata Dosha, Pitta Dosha and Kapha Dosha. These Doshas consist of two out of the five elements ether, air, fire, water and earth respectively. One individual composition of these five elements and thus of the Tridoshas is attributed to each human being. Everybody has the duty to keep, or in case of illness to recover, a balance of these elements and Doshas through an adequate life style and diet, which are taught in ayurveda (Ayurvedic Foundation).

Ayurveda practitioners who either studied ayurveda or follow a family tradition as Vaidhyas and have been trained by their parents, produce the herb mixtures they prescribe themselves or have them prepared by ayurveda chemists (Gartoulla 1998:81). Apart from herbal mixtures they also use massage (Shankar 2001). (24)

Traditional Tibetian Medicine

Practitioners of Tibetian medicine belong to two groups: first the Amchi, the herbal healer of Tibet, and second, some Lamas, Tibetian healers, practice the so-called ceremonial healing, i.e. healing through mantras and meditation (Dietrich 1996) (25).

The Amchi passes his knowledge along to disciples, in the past often to his own children. The disciples accompany their teacher to gather experience, they learn to recognize and find medicinal plants and to produce herbal remedies. They also learn moxibustion (26) and other techniques as well as astrology, which plays an essential role in Tibetian medicine.

In 2003 a special clinic for Tibetian medicine was established in Kathmandu, and four small private institutions train Amchis in Nepal (Himalayan Amchi Association).

Obviously a strict differentiation between religious beliefs and practices within the wide range of traditional healers in Nepal is impossible.

"To solve human needs and problems the gods have several alternatives. One of the most important alternatives is to empower a few chosen persons through dreams to help cure sickness and diseases. So, for example Dhamis and Jhankris (Shaman-healers) are perceived people chosen by the gods to save and nourish their creation." (Gartoulla 1998:120)

IV. Results

An astonished look from my Nepalese fellow-student while we are sitting in the conference room of the Tribhuvan University Teaching Hospital and waiting for the early surgical meeting to start. I had only asked him a simple question: could he tell me something about the various healing traditions in Nepal? I can almost read his thoughts: this German student, who is lucky to study medicine in Europe and - for unfathomable reasons - spends part of her practical year in such an underdeveloped and instable country as Nepal, shows an interest in these unscientific alternative healing traditions and the superstitious beliefs involved.

"Are you serious, you are really fascinated about medical anthropology, especially in Nepal? You know, we medical students here, we all hate that subject, it's the most boring thing we have to study in the first year of our course."

This was more or less the reactions of most of my Nepali fellow-students whenever I wanted to learn something about traditional healing methods or spoke of my ,course in ethnomedicine". This is why I did not even mention the fact that I had sat together with shamans in the evenings, drumming and learning their mantras, that I had even experienced some Chintas myself. Most of them, the surgeons in particular, but also the medical students I was together with in courses and on the ward, expressed astonishment and incomprehension. Consequently, I led something of a double life: by day I was the German medical student who changed dressings and was allowed to suture skin in the operating theatre, in the evenings I turned into the disciple of a Nepali shaman!

"The treatment of a disease depends upon what is held to be the cause of that disease. If an educated man believes that the cause of disease is naturalistic, he contacts empirical medications from various sources such as drug-peddler, drug retailers, grocers, community leaders, doctors etc. In a similar fashion, if a man believes the cause of a disease to be the wrath of god, influence of an evil spirit, sorcery or breach of taboo, he consults/practices appropriate agencies for treatment by witchcraft and magic, charms, amulets, or even sometimes uses ethnomedicine where they are held to possess magical properties", writes Gartoulla (1998:80) in his analysis on the use of ethnomedicine therapies in Nepal.

Patients with a traditional view of illness often find it illogical that the physician with biomedical training only records one pulse while the shaman is able to distinguish between up to three different pulses per wrist (see Gartoulla 1998:166).

FIGURE 9. Shamanic puls diagnostic

The fact that biomedicine mainly treats patients independent of their family and social environment also contradicts the understanding of many patients in Nepal of disease as a "family and social affair" (ibid:166).

"When used to the intense and elaborate efforts of the dhami, the behaviour of the health post staff can seem unsatisfactory to most people. "In the health posts they just give the same pills to everyone" was a rather common complaint.
For a sick person in Bhojpur, going to see a traditional healer implies more than consulting a health specialist. Seeking the help of a dhami means seeking a cause and explanation beyond the immediate symptons of an ailment, and requesting assistance from greater healing powers", writes Kristvik (1999:77) on the basis of her experience in east Nepal.

Biomedical physicians often dismiss information given by a patient who from a traditional understanding of illness (27) believes this information to be relevant and essential to diagnosis and resulting therapy; this contributes to misunderstandings between physician and patient and makes some patients think they are not understood properly (Gartoulla 1998:166).

In addition, patients criticize the chronic lack of time for extensive interviews in biomedicine and likewise examination of a patient, but also long-term and therefore costly therapies with medication. These may be seen as additional obstacles for a stable doctor-patient relationship and subsequent patient compliance.

At the Teaching Hospital in Kathmandu, and also at the Western Regional Hospital in Pokhara I found that the simple question of costs for treatment and everything involved - trip to hospital, stay in hospital, food, medication or surgery - will decide whether some patients consult a shaman or other traditional healer first who assesses the complaints and gives an appropriate diagnosis. This tendency is probably stronger in rural areas where medical facilities are scarce.

Another important point is that patients do not see biomedical therapies and traditional healing methods as mutually exclusive options but in many cases make use of different therapy approaches consecutively or simultaneously. (28) What we see is therefore a plurality of healing systems on one hand and a pluralistic approach in using them on the other.

According to Pfleiderer, this "oscillation between different interpretation patterns" (Pfleiderer 1982, in Böker 1992:46) is a characteristic of changing societies in so-called developing countries - a description that fits Nepal as well.

From a perspective not only of patients but also the respective healing systems, the following tendency is obvious: The differentiation and confrontation between biomedicine and traditional healing in Nepal appears to come mainly from representatives of biomedicine with an academic western education, as I found personally and learned from a number of research reports on the subject. While shamans with their holistic approach do not see biomedicine as serious competition (29), some biomedical physicians feel shamans are a threat to the population and a nuisance and may undermine patient compliance with scientific therapy approaches of western orientation. Why do biomedical physicians in Nepal have such problems accepting other, more traditional forms of healing?

Some diagnostic and therapeutic approaches of Nepali shamans appear "strange", perhaps even "mystical" or just like "conjuring tricks" at first sight. Biomedics object that shamans have no scientific training, that their approaches are based mostly on assumptions that cannot be verified nor repeated, i.e. they criticize the lack of scientific determinism according to which all natural phenomena show a strict causal connection. Shamans often prescribe herbal remedies but mostly without a scientific basis in the Western sense (see also Gartoulla 1998). (30)

The missing scientific foundation and the alleged ignorance of shamans are superficial explanations for a dualism of biomedicine and traditional shamanistic healing in Nepal.

The core problem, as Prof. Dr. Nepal confirmed in his interview, is that traditional medicine is seen as a synonym of backwardness and is therefore stigmatised (31), while Western biomedicine is a synonym for modernization, education, progress, technology and development. The dualism described has therefore grown and been supported by Western development aid with its mainly ethno-centristic attitude, specifically at the beginning, in Nepal (32).

Everybody who believes himself to be educated and modern and wants to demonstrate this must therefore oppose traditional medicine! The result is a confrontation between Nepali biomedics and traditional healers but also between various ethnic groups (33).

Prof. Dr. Nepal told me in his interview: ,You know, general educated Nepalese nowadays they know these are traditional healers and they represent all the old, primitive things, are uneducated, illiterate people. Medicine is modern now, you must look for the hospital doctors, doctors trained in Germany or in where ever. (...) There's one question: it's of stigma. Stigma, you know, these peope [the shamans] are uneducated, illiterate village people and if we [the biomedics] try to relate ourselves with these people then it's not so good, you are considered again low."

We may summarize with Kleinman: "As long as biomedically trained experts, influenced by scientism, treat healing as an independent, timeless and culture-free process, they will have difficulty in appreciating the holistic nature of indigenous etiologies and therapies." (in Davies 1994/95)

In contrast, traditional healers do not appear to see biomedics as competition.

FIGURE 10. Traditional healer Parvati in front of her ritual objects

FIGURE 11. Traditional healer Parvati in front of her ritual objects

"(...) If my diagnosis reveals a supernatural cause, then I will proceed with treatment. If not, I will refer the patient to a doctor. Also, if a bodily ailment fails to respond to my repeated attempts to cure it, I will send the patient to a physician. Problems that we cannot cure are those that involve physical damage to the body, such as broken legs, severed limbs and cuts. These patients must seek modern medical treatment." This is how a Phombo, Jirel shaman in east Nepal, describes his view of biomedicine. (Sidky 2000:49f)

Shamans even seem to adapt to modern influences in Nepali society to some extent:

"One of the most striking things about the contemporary alternative health care scene is the vitality displayed by traditional systems and their practitioners not in carrying on in an unchanged fashion, but in adapting their etiologies, therapies, and rituals to meet the expectations of their traditional (and new) clients who are also adapting to the modern world and its ways ." (Gartoulla 1998:164)

The danger of too much westernization in therapy approaches must be underlined in this context. Skultans writes (1988 quoted in Böker 1992:47) that in Kathmandu in particular, the practices of some traditional healers are increasingly mechanistic, above all in the speedy treatment and unpersonal atmosphere. I have not seen anything like this myself, but can easily imagine such potential results of a hasty adaptation to modern influences.

Kristvik (1999) confirms that shamans are highly flexible, creative and adaptive in reconciling modern Western influences with traditional methods and putting them into practice:

"A distinction between diseases needing intervention from a doctor, and others requiring a dhami's assistance, can hardly be part of a very old tradition in a place which has only had health posts for a generation or so. Rather than being static, rigid ways, the practices of the Dhamis in Bhojpur seemed to be in a constant flux. Their statements and behaviours reveal a tendency towards complementary co-existence with modern health services, sharing patients with the professional health workers. But the possibility of a competitive line is also evident, in which case patients will be warned against going to the health post." (Kristvik 1999:98)

She addresses the problem of actio and reactio also discussed by Stone (1976:78): if health care practitioners see shamanistic healers stigmatized with backwardness, and if they also stigmatize those patients who come to the health care facility after a shamanistic healing attempt, then their attitude must provoke a re-action, i.e. a separation of traditional healers. A possible reaction is that shamans reject biomedicial approaches, and that they pass on this attitude to those who consult them. The patient has to make a clear and definite decision, he is forced to choose between shamanism and biomedicine without the option to use both. This type of action and reaction (34) is an additional hurdle on the path to a cooperation between shamans and biomedics, which finally might become impossible. A hardening of the lines, a further separation between both healing systems and even a greater rift in society are possible consequences. Obviously this paper highlights only some tendencies and extremes and cannot assume to give a comprehensive picture of the many assessments and opinions on traditional healing and biomedicine in between. (35)

Another, and in my opinion most important, aspect of the debate on dualism or a possible synthesis of biomedicine and shamanism is how both systems get on and communicate with each other. Both sides expect respect for their own knowledge, methods and therapy results; but biomedics in particular often have problems recognizing such knowledge and successful outcomes on the other side, since biomedical methods appear incomparable to those of traditional healers. But both approaches are less different than might be assumed at first sight:

Peters (1979) in his article ,Shamanism and Medicine in Developing Nepal" illustrates that psychiatry, psychoanalysis and psychotherapy use concepts similar to those of Nepali shamanism. Conflicts in the domestic or social context frequently require a shaman's intervention. Shamans use their healing techniques not to eliminate organic disorders but try to help where emotional balance and human relationships are disturbed.

I would not subscribe to this view without reservation. Certainly many problems taken to the shamans are located in the socio-psychological sphere and may be treated in a community-centred approach aimed at social (re-)integration. But in my experience this does not exclude the treatment of organic problems by shamans. The shamans in Naikap I saw in their healing procedures also treat fever, strong headaches, diarrhea and similar disorders, i.e. physical complaints. But keeping the concept of psychosomatic illness in mind I would agree with Peters (1979) to a certain point, since not all physical symptoms have psychosomatic interpretations and explanations. Corresponding to shamanistic methods of healing a patient through a ritual, we see techniques like e.g. NLP and biofeedback in Western medicine, or the much-discussed placebo effect (Kristvik 1999:111ff).

"Just by naming the disease there is immediate reduction in the patient's anxiety. This is because, once the illness is put into a cultural frame, definite expectations are aroused in the patient and his family. (...) It does not matter what the name is; it can be a psychological complex, a biological organism or a masaan. (...) The diagnostic process through which illness is identified enables a transformation from chaos to order in the eyes of the patient and those concerned for him, and this has therapeutic effectiveness." (Peters 1979:34)

No matter which system is assessed in the light of the above statement: biomedicine as well as shamanistic healing enable a patient to handle his perceived complaints better - depending on his personal interpretation of his symptoms: a biological-scientific, cause-oriented explanatory model, or rather supernatural powers. The important thing in this situation is to offer a supportive structure for the patient, and a conclusive picture of the symptoms that confuse and frighten him. Thus the patient is empowered to act (36).

V. Summary

A wide variety of factors decide which type of healing a patient chooses, as Dr. Gartoulla confirmed in his interview. These are a patient's income, social status, caste, age, religiosity, education, advice from family and friends, and personal experience with illness, among others. The essential point is how a patient assesses the nature of his illness and its cause, and this depends on the symptoms and his understanding of them. Beine (2001:163) mentions a ,symptom based treatment seeking strategy".

"Depending on which healer had been consulted, the cause of the illness could have been attributed to anxiety, an upset in the hot-cold balance of the body, witchcraft, intestinal parasites, or a malevolent ghost. The method of diagnosis could have involved the reading of the three different arteries in the wrist, an x-ray machine, or a consultation with the spirits. Cures could have ranged from surgery to exorcism. Not only techniques, but philosophies would have varied; seeing illness as due to the conscious actions of the gods (or, in the case of witchcraft, humans) is vastly different from viewing it as due to impersonal actions of germs." (Blustain 1976:84)
"(...) medicine is based upon faith - faith in the ability of the healers, faith in the methods of curing, and faith in the philosophy and cosmology upon which the system is built. A westerner unfamiliar with the village curing practices would undoubtedly look upon the trance of the jhankri with amused horror. Similarly, the increase in hospital visits over the past seven years is indicative of the faith the villagers are increasingly placing in the hospital.
No system of medicine can guaranteee a one hundred percent rate of cure. A patient in the west whose condition does not improve does not resolve that he will never again enter a hospital. Rather, he might ascribe the failure to the incompetency of the doctor, to a faulty diagnosis, to a malfunction in the testing equipment (...). The villager as well has means for rationalizing medical failures. (...) As with the western patient, faith is never shaken in the basic validity of the system." (Blustain 1976:102f)

Kristvik (1999) in a study on tuberculosis therapy and prophylaxis between biomedicine and traditional understandings of health underlines the need for incorporating traditional healers and traditional understandings of illness in all efforts to fight illness in Nepal. She sees shamanistic healers in a key position. A Norwegian nurse, she is well aware how difficult dialogue and resulting cooperation between biomedics and shamans really are.

Both sides would have to make concessions in order to bridge the historical gap between biomedicine and traditional arts of healing in Nepal: they would have to meet on the same footing, to accept the experience and methods of the other side and to give up artificially maintained competitive attitudes. All this presupposes a willingness to study the medical approaches of the other side and to make a serious attempt at dialogue and understanding.

"Understanding seeks an identification with the experience of others without which no true interpretation is possible." (Kakar 1982:209, in: Dougherty 1986:35)

Efforts must be made to transfer the focus from seemingly insurmountable differences to common elements in both healing systems. As described above, a closer look reveals a host of commonalities. Ultimately, the philosophy underlying both systems may be reduced to the question of existence, of living and dying as such, independent of culture-specific explanatory models:

"Both medical and indigenous practitioners are involved in attempts to understand more of the mysteries of life and death. Both attempts are necessarily incomplete and undergoing constant change." (Kristvik 1999:101)

VI. Discussion

Several decades ago, the integration of traditional medicine into, or participation in, a nation's health care system was a subject of intensive debates on scientific, but also specific development policy related and medical issues. The discussion was mainly triggered by the WHO declaration of Alma Ata in 1978 that defined health for everybody by 2000 as an objective of all national and international health care efforts and gave considerable attention to an integration of traditional healers. (37)

Research of so-called herbal medicine as part of traditional healing receives much attention in this declaration. What at first sight seems to be an open-minded ethnomedical approach appears rather critical, however, with a closer look at the way in which the WHO intends to integrate traditional healers in the health care system. I agree with Kristvik (1999) who warns against efforts to sell off traditional knowledge, and marketing through multinationals, specifically for vegetable substances. I recall the repeated and on-going legal battles for patents between indigenous groups in the Amazonas region and multinational pharmaceutical companies and efforts to protect millenium-old knowledge of rain forst medical plants.

The WHO document (1978) also mentions, as pointed out by Kristvik (1999), ,radical development and promotion of traditional medicine (...)". The guidelines are even clearer:

  1. Giving recognition to traditional practitioners and incorporating them into community development programmes.
  2. Retraining traditional practitioners for appropriate use in primary health care.

Davies (1994/95) finds a more drastic way of expressing this attitude:

"(...) the PHC planner has a moral obligation to include traditional healers, so as to oversee them and eliminate any possible dangerous practices."

What the WHO document, point 1, presents as placing traditional healers on the same footing with biomedics, is almost completely reversed in point 2 (38): the guideline plans to train the traditional healer ,properly" - in the biomedical sense, in order to send him back to the village as an (advertizing) expert in biomedical procedures and diagnose patients for biomedical symptoms in order to refer them to biomedical health facilities; this happened e.g. to promulgate oral rehydration solution, nun chini pani, as therapeutic intervention for cholera and other diarrhea-related diseases, but also birth control measures in rural areas. For some time, this was successful and some healers cooperated actively but lost interest quickly (Kristvik 1999).

Biomedical training for traditional healers is certainly well-intentioned and may even help to reduce epidemic diarrhea and high death rates as a consequence. However, this perspective neglects the healing knowledge practiced by traditional Nepalese healers for thousands of years, and just dismisses its effectiveness.

As Prof. Dr. Nepal underlined in his interview, the shaman is not accepted as equal but rather is instrumentalized by the biomedical system on the basis of his influence in rural areas and his close connections to the village community - qualities which biomedical physicians have never developed, specifically in rural areas of Nepal.

Jochen Diesfeld (1974) summarized these aspects in a lecture on the integration of traditional healing systems into national health care strategies in developing countries and suggested reasons why biomedicine still has acceptance problems in traditional and above all rural communities.

"In this context I do not intend to analyse traditional medicine for effectiveness or harmfulness from a scientific perspective but underline that in a traditional society it achieves what western scientific medicine has not achieved there up to now, that is, to be accepted and to address and meet the felt needs of individuals and the community.
Modern medicine operates absolutely outside the social and spiritual context of traditional societies. If in addition we consider that this exported scientific medicine is exclusively informed by the social and spiritual context of its countries of origin, then it is even more obvious that this is not only export of scientific medicine but of medicine formed and developed for the culture it emerged from. We must be aware that western biomedicine, too, gains much of its knowledge on illness and treatment from empirical observation and therefore resembles so-called traditional medicine in this respect.
So-called natural-scientific medicine also contains many elements marked by traditional behaviour patterns without scientific validation the scientific analysis of which started only recently.
The impact of western civilization and the resulting destruction of traditional social patterns has another consequence for health in the widest meaning of the word. It destroys traditional forms of social security without which there is no health. In this respect we are less able to procure adequate replacment than in the more strictly medical field." (Materialien zur Ethnomedizin 1978:93)

This applies particularly to the situation in Nepal. In the 1970s a large number of anthropologists, sociologists and ethnologists from all over the world started to study the effects of biomedicine in Nepal on the patients' concept of illness and their selection of a healer - i.e. either traditional healer or biomedic, and the mutual influence of the different medical systems on each other then and today.

Blustain (1976) summarizes his observations made during field research in Saano Dumre between 1974 and 1976 as follows:

"(...) the Nepali villager's concepts of medicine are not a tabula rasa upon which westerners can freely impress all sorts of notions about viruses and antibiotics. Nor is the problem one of finding ways of replacing village methods with more "scientific" ones. While the hospital unquestionably has much to offer in the treatment of diseases, it could never preempt the psychotherapeutic role of the jhankri. If health care in Nepal is to be improved, one must start with the assumption, that the villagers' faith in their own healing techniques - be they herbal or ritual - is not going to be shaken by the occasional visits of medical teams or even by the building of hospitals. The problem facing the public health workers is one of finding the means of integrating western ideas into the village system. From the villager's point of view, the process has already begun." (Blustain 1976:103)

Similar to many parts of Africa (39), the majority of biomedical cooperation projects with traditional healers in Nepal are seen as problematic, if not failed (Kristvik 1999). The reason Kristvik gives is the one-sidedness of so-called "training sessions" where traditional healers were trained in biomedicine but without receiving something in exchange from the health workers, i.e. not so much financial incentives but rather recognition of and respect for their work and traditional skills. These training sessions, originally aimed at an exchange of knowledge, normally turned into attempts to break traditional healers of their ,bad habits".

Personally I also detected this attitude, often subconscious and widely held among enlightened project initiators and staff with academic training, when I interviewed Prof. Dr. Nepal. He described a cooperation project with shamans on psychiatric care for the population of Kirtipur in the 1980s with the following words:

"So, we interacted with them and then we taught them that, if you have patients of this sort, you know, then you send these patients also to the health post, nearby health post, where paramedics have been trained to identify epilepsy, to provide anti-epileptic medicines, identify psychosis, give anti-psychotic medicines ...like that. But if you (addressing to the shamans) have hysterical disorders, affective disorders, don't send these patients here. You just manage on your own. The only thing you do, you don't extract too much money from the family. Don't try to make a lot of money out of them and don't try to abuse the patient. Sometimes, you know, they burned (40) the patient, they do all sorts of things, physical damage to the patient's body. Don't do that: beating, heating, nailing, burning - these sorts of things don't do, don't extract too much money. You just manage on your own. And those patients in which epilepsy is there, send these patients here, anti-epileptic medicines have to be given. And: it worked very well!"

Although the revolutionary character of such a project in Nepal in the 1980s and the enthusiasm with which Prof. Dr. Nepal reports the successful outcome clearly reveal that he seriously wants cooperation with shamans in Kirtipur on the basis of partnership, he is still a victim of his own socialization and western training: certain personal values - not to demand too much money from patients and not to submit patients to drastic interventions - become preconditions for smooth cooperation with shamans. A well-intentioned and often hidden kind of behaviour control - an admonitory finger!

Nevertheless, Rätsch (2000) and Kristvik (1999) report a few quite encouraging, albeit small-scale, attempts at cooperation between shamans and biomedics (41); even if it was not possible to transfer the results to standardized nation-wide programs nor to analyse long-term tests. The TB program of the British Medical Trust where Kristivik (1999) did her field research served at least to improve communication between healers and biomedical health care staff - surely a step in the right direction.

"If the professional health workers were to recognize the dhamis as health workers in their own right, it would be a challenge to the hierarchical order between the high and low castes, the urban and the rural, the educated and the illiterate, which is not a minor thing. Opening up for co-operation with traditional healers would imply that the doctors must let go of some of their control, prestige and power." (Kristvik 1999:131)

Representatives of western (bio)medicine are still unprepared to do so.

But the status quo in health care in Nepal as described above demands a definition of problem areas and pertinent measures that might serve to improve the current desolate situation:

"First, the progress of western medical education is a very recent phenomenon in Nepal. Secondly, institutional infrastructure for reaching modern medical treatment for everyone is far from adequate. Thirdly, the spread of general education itself is not yet satisfactory. Due to all these and other causes, ethnomedication and other traditional healing practices have continued to be much relevant in the Nepalese context (...)." (Gartoulla 1998:78)

This means that health care in Nepal, either in project planning or in the implementation of health care strategies, requires studies of traditional healing structures and the pertinent understandings of illness and health. But it will be necessary to redefine the type of such studies and the attitude for addressing traditional healing methods, to reconsider approaches that failed in the past, and to ask new questions:

It is not enough to find out what the cause of an illness is (as biomedics usually do), but the patient wants answers to the why: why am I the one to be affected, why me, why now? The patient wants explanations that go far beyond the biomedical explanatory model for illness and require profounder exploration of issues concerning human existence, life and death. The patient wants somebody to help him placing his illness into his individual, socio-cultural world view in a way that makes sense to him. (42)

So much on theoretical background; but a far more difficult question to answer is: how can, should and may all this be embedded into a concept that works and is supported and furthered by all involved, and also integrated in practice?

First of all, we see from the above that Nepal as a nation, and therefore the illness concept of its population and the kind of planned diagnosis and therapy, are in a process of change.

Beine (2001) has a very graphic way of describing changes in the understandings of illness and treatment options among the people in Saano Dumre who Blustain (1976) had interviewed on the same issues 25 years before.

Beine (2001) sees the medical pluralism he finds there as a "hybrid system", a maximization of therapy offers through a combination of traditional and biomedical approaches, with regard to the explanatory model (EM) of the population but also to the therapists involved.

"(...) in one domain (home remedies), products of western development are being applied in an ingeniously indigenous fashion, while in another domain (spiritually perceived sickness) the traditional healer's practices are being modified to incorporate new beliefs in the efficacy of western medicine. And in another instance the use of traditional healers is being modified to exclusive use in one domain only (,shaking" illness)." (Beine 2001:164)

Beine's (2001) interviews reveal interesting results:

88 % of people interviewed in Saano Dumre said they go to the hospital if home remedies fail, only 12 % went to the traditional healer. Shamans were consulted mainly in case of suspected "shaking illness" (43). Most frequently mentioned groups of important causes of illness were: pathogenic agents (64 %), negative influence of planets (24 %), bad karma (16 %), spirits (3 %), physical weakness (8 %). 76 % of those interviewed said they consulted the dhami-jhankri less frequently than 25 years before.

FIGURE 12. Traditional healer Maile drumming

Biomedical explanatory models for illness, in particular the concept of germs and biomedical explanation of contagiosity (44) of certain diseases find increasing acceptance among the population. But traditional explanations, for example attacks by evil spirits or witches, are also preserved. Beine (2001) continues to describe a growing awareness among shamans that some types of illness may be cured better by biomedics in hospitals and therefore they send their patients to the biomedical clinic if their shamanistic interventions fail or even immediately after addressing gods and spirits for diagnosis.

It remains to be seen whether Beine's observations also apply to other rural areas in Nepal and what has become of his conclusions today, almost five years after his field research and under the influence of the "People's War". To my knowledge many NGOs have withdrawn support and personnel from their hospitals in rural and remote regions in Nepal, or have drastically shortened their health services (45), due to continuous harrassment by maoist fighters, for example at the Am Pipal hospital, one of the biomedical health care facilities analysed by Blustain (1976) and Beine (2001) (46). Fears among the medical staff and lack of supplies due to road blocks further contribute to endangering health care services. Therefore it would only be logical that shamans and other traditional healers now assume more of their former tasks they had already passed on to the clinics.

It must also be noted that Beine (2001), similar to many ethnomedical research reports, analyses the situation on a theoretical level but does not suggest practical ways to implement necessary steps - at least not in his publication, although his discovery of the "hybrid system" suggests a number of useful approaches.

As a consequence of all this, I see the willingness among biomedics in Nepal to get involved in medical projects combining shamanism and biomedicine as rather limited to date. But perhaps western biomedics are able to give some impetus and re-import (47) traditional shaman knowledge from Europe to Nepal and thus promote an interest among biomedics in Nepal. My suggestion for testing a ,hybrid system" in practice is based on the concept of a combined, integrative approach involving physicians and traditional healers: if the patient so wishes, biomedics and shamans might try to assume joint responsibility in the care and treatment of this patient (48). One field where I imagine this might be feasible is obstetrics. Pregnant women for example might consult shamans to be purified from negative influence or receive amulets and protective mantras, and on the other hand they have the chance of basic check-ups and preventive examinations or of biomedical intervention in case of complications at birth. A real hybridization would also require a midwife to complement the team, to be present at birth and support mother and child after birth. A basic precondition would be the above-mentioned willingness to study the other approaches, to communicate at eye-level, to give mutual support and to learn from each other. The overriding intention must be: to treat patients in the best possible way to recover or maintain health on a physical, mental and spiritual level.

Applied to Kleinman's model, this may be seen as an effort to integrate both sides of the coin - disease/curing and illness/healing - in a holistic manner into an approach that aims to remove sickness and thus to address patients' complaints in a far more comprehensive way.

Young (1983:1210) postulates on traditional healing methods complementing biomedicine:

"On the other hand, the traditional practitioner's strength is in healing patients rather than curing them - i.e. giving meaning to biomedical events rather than controlling them. To the extent that this is true, we can conclude that traditional healers (a) provide a legitimate medical service (healing illness) and (b) complement the curative services provided by the official medical sector, reduce patient dissatisfaction, and diminish the causes of maladaptive behavior."

This integrative therapy approach might find acceptance among patients, as may be seen from Durkin-Longley's (1984) article ,Multiple therapeutic use in urban Nepal". She reports her observations:

"(...) clients resort to different healers simultaneously to manage different aspects of their disorders." (ibid:870)

Obviously, the integrative approach described above must be seen as simplified and rather sketchy and also incomplete in view of my biographical background; nevertheless I believe it would be worthwile to put it into practice. This would require some preparation: first a team must be organized consisting of shaman, midwife and physician, team members must build trust and have opportunities to be present when the other approaches are practiced, must learn some basic principles themselves or at least receive explanations. Communication in one language - Nepali seems a good suggestion - requires some preparation, too, certainly for the biomeds with western training. Such an experiment may require so much preparation, planning and implementation that it could become a life-time mission for all involved. The intention therefore is not a short-term research project but rather a continuous and joint effort in the interest of patients. I believe results from such a team approach would be highly interesting: an integrative approach with a focus on commonalities and advantages of the different systems of healing and the intention to put them into practice on the basis of equality.

In conclusion I quote once again Prof. Dr. Nepal, head of the psychiatric department at Tribhuvan University Teaching Hospital. Considerable obstacles will have to be overcome in order to achieve real cooperation of both systems - biomedicine on one, and shamanism on the other side; but there are some personalities who are willing to assume this mission and to take possible steps on converging paths to an understanding.

"Biomedicine has some advantages, good things. This alternative, complementary medicine has certain advantages, certain good things. And what patients need, what societies will need: best of the two things. You know, if something is working here, if it is better on this side, why not to take it? There is good on this side, why not to take it? Whatever patient care, care of the patient, is, it's the best of the two worlds what we need. Not thinking of this is, this comes from rural area, this comes from the illiterate part of society, this comes from lower caste group. No! It is working, it's worth. It has to be blended."

Let us hope that one day a confession of one's own weaknesses and an acceptance of the opposite approach will bring us to the decisive point, where a patient's recovery through an individual, patient-oriented combination of different healing approaches becomes reality.

"But change is possible - even in Nepal!" (Prof. Dr. Nepal in the interview)

Appendix

Interviews

1.1. Prof. Dr. Mahendra Nepal, Dep. of Psychiatry, TUTH, Kathmandu Date: 7.11.2005

Carolin und Marcus (C&M): Maybe you could just introduce yourself and give a brief summary on the topic and the interest you have in medical anthropology. So, we can start with the summary:

Prof. Dr. M. Nepal: I'm a psychiatrist and my name is Dr. Mahendra Nepal. I'm a psychiatrist trained more in the western medical way. I was primarily trained in India and then other places. And I've been working as psychiatrist in this hospital in Nepal since 1986... and, what else.... I've been, in that, I'm also working through the community mental health programmes in the villages through this mental health project.

C&M: So that's the point where you come in contact with the shamans?

Prof. Dr. M. Nepal: So, there we come in contact - in community mental health programmes in the villages, there we come in contact with traditional healers. And so we've already worked on mental health in the villages, so traditional healers are there and you got to interact, you are bound to talk to them, interact with them, take them in your confidence and like that. They have been providing psychological services to the people for a long time, so psychiatrist...Nepal has just a few, less than 45 psychiatrists, counselor psychotherapists very few, 3, 4, 5 such as this. The large number of Nepali people, they are receiving their psychological support, emotional support, counseling from these traditional healers, not from recent times, this is from ancient times, since four thousand, five thousand years. So that tradition is going on. And then when we talk about modern psychiatric care, modern mental health care, so we have to interact with these people also in the village level and my limited interactions are there trying and work with them in that setting.

C&M: What are the causes for patients to seek either the shamans or the biomedical doctors? Is it only psychiatry, or also other causes ?

Prof. Dr. M. Nepal: In the village setting these traditional healers are very influencial, very powerful. They are called... in many places they are called "jannes", janne means someone-who-knows. A fountain of knowledge. So, village people, if they have any problem, medical problem, any problem, problems like life problems from birth in the family, death in the family to marriage issues, to fights, quarrels inside the family, to financial crisis problems, fever, diarrhea of the children or psychiatric problems ... anything, so these are the first people who are contacted, consulted. So in the village setting, Nepali village setting, educated people like these people will be, will have some knowledge about the outside world. Then usually there is a school nearby, this school teacher will be educated a little bit, he will know, he will have some information, some knowledge about certain things. Then there are health workers, not doctors, because Nepal doesn't have enough number of doctors to send to each village. So there are non-doctor-, non-physician-health-workers....ehm...or nurses, different kinds of paramedics. Either these people are nearby or school teachers are there, or these traditional healers. So these people are the first ones who are consulted, like "my child has got diarrhea. Now what to do?" So, this person will make a decision: okey, I can give you some herbal medicines. He'll be alright! Or he'll decide "No, this I cannot do much; you take him to the health post, nearby health post or take him to the hospital, which is the district health post or to the doctors house which is two days walk or three days walk or whatever". So this person makes the decision and then for minor ailments, physical ailments he manages with the herbal medicines, and also for the psychiatric things, also he manages. So his method of management is, one has to learn, one has to understand what he does, what he or she, it's not only he, not really biased towards male, but it could be she also. And they come in a different.... Nepal as you know is divided into three different topographic zones...unlike Germany. Nepal is a smaller country, but lot of variety, because of the topography. Germany you drive from... how many hours you take to drive from Munich to Hamburg? In 8 hours you can reach? But to reach from north to south here, 8 hours is not enough. It's a problem! Transport communication is a problem and topography is the problem. In the high mountains at least... if the roads are better then within half an hour you can drive from the sea level, 200 feet from the sea level, to four thousand feet within half an hour, if there is a road. If there is no road, then you'll have to walk for days. So this unique topography Nepal has, has brought a lot of variety. So there are different types of people, ethnic groups, different caste groups, different religions, they are there since centuries for thousands of years living together, but they are so different. And the east part of Nepal is different from the west part, southern part is different from the north part.... All variety, languages are different, there's around 90 different languages in this small country. Can you imagine that variety? And even the flora and fauna, the plants and insects, these animal sorts are different. North side you got Tundra, snow covered mountains almost like your northern european.. north Finnland or north Norway type of things. Go to southern part it's very tropical, it's heat and dust, it's moist, it's dusty also you get mosquitos.... Within one country, small country lots of variety! So... here also according to the different race groups, different ethnic groups the traditional healing practice has differed, that also is. So among the Brahmins there is different sort of traditional healing, Tamangs different, different, Rais will have different, Magars will have different, Gurung caste will have different. They have their own healing traditions and practices. And...although there are certain commonalities, certain things are common, but again the rituals, the practices, other things are getting differed from place to place and from each region, each caste group to other caste groups....okey? So, there is variety there also, in healing practices also, there are lot's of reasons: like some will pray to the sun god, some will pray to the goddess of the forest, some will pray to the goddess of the family also something....Some use mixture of ritual, magical treatment as well as herbal medicines, some purely herbal and then there are ayurvedic practitioners - you know ayurvedic practitioners? - who are more university... they are more educated, they have university education and all. So, they are also used, but Ayurveda is one of the ancient Hindu medical treatment methods.

C&M: Is this common here in Nepal?

Prof. Dr. M. Nepal: It's common. Like in villages it is quite common, in urban areas a little. It is quite scientific. Ayurveda is the oldest medical system, but is was... it could not grow... it could not develop.., because the Indian subcontinent - it was in this part of the world - was invaded by the Muslims, the Muslims who came from ...ahhh..... more from Afghanistan or from that side the invaders came. So they invaded in the 5th century, 6th century, massive ...they killed lot of people and in all this schools were distroyed, ayurvedic schools and things were distroyed. So, it could not grow. Some of the concepts of Ayurveda was taken by Arabic Ayurveda people...and then it went to Europe from there, it travelled to Europe from there. But in Europe the Renaissance period came - you know Renaissance period? - the period of revival in Europe. When? 14th, 15th century? Renaissance? 17th century or 16th century. So when the science started growing, so that time some of this basic medical principals which was taken from ... originally from the Ayurveda from here, which travelled to Europe by the land route through Arabic people and then there. There then it developed as a medical science. Whereas here, it remained at the same stage. Okey? So the oldest textbook of medicine, oldest textbooks of surgery, ayurvedic surgery, was written. There was a surgeon Sushruta - do you know that? - there was a physician called Charaka. So Charaka used to be the physician and used to be placed in a university - the first universities of the world were here, not Oxford or Cambridge or Heidelberg or... No, here. So there was a place called Taksashila, sanskrit word is Taksashila, now it's called Takshila. Now it is in the Pakistani side. Only ruins are there. Everything was destroyed by the invaders from outside. So there this physician Charaka used to practise medicine of that time, ayurvedic medicine of this time. Sushruta used to practise near Benares, in Benares, Varanasi, and near Nalanda. Nalanda is in the Indian State of Bihar. So there was another big university there. That was again, that was destroyed. If you read the Sushrutas they, that time, they describe how to do appendicectomy. They describe how to repair fractures, they describe how to remove cataract. Many such things are described.

C&M: When was this written?

Prof. Dr. M. Nepal: I can't give exact dates, but around 1500 to 2000 years back. But now what has happened was, it was written in the Sushruta Samhita called (???) .....So the (???) are there, like if your patient has these symptoms, he might be suffering for appendicectomy and this has to be... appendicectomy has to be done, is written. But it was not practised. You know, the actual practice part was not done since that time. At that time how did they practise? We don't know. That time, since the person who wrote that Sushrutas time, there's no anesthesia, there's no x-ray, there's no lab-test, but then it was lost in between. But the books are still, such as practical surgery and medicine are still there. So these are ayurvedic practitioners, are traditional medical practitioners and they also exist very much. Especially amongst the Brahmin's and Kshatriya's communities. What else you have to ask?

C&M: I heard about the PhD work that was done for the university of Tokyo, you talked about it in the annual conference here. The topic was how to implement traditional, trained traditional healers in the Nepalese health system. Maybe you could give a brief summary on this and tell your idea how you think traditional healers could be implemented to guarantee a nationwide health care system in Nepal?

Prof. Dr. M. Nepal: I forgot that. Is it a PhD in Tokyo? I'll have to check that.

C&M: You said that in the annual report and I just noted it down. Yes..

Prof. Dr. M. Nepal: We'll have to check that again. Exactly... The traditional healers, as I said earlier, they are the ones who are providing the mental health care at the village level. So, when we started working with traditional healers, so we found that they are the ones who are handling everything. All the mental health problems, isn't it? And so we found them quite useful in many different ways... and we, we thought that we must work in collaboration with these people rather than antagonizing with them. You know, general educated Nepalese nowadays they know these are traditional healers and they represent all the old, primitive things, are uneducated, illiterate people. Medicine is modern now, you must look for the hospital doctors, doctors trained in Germany or in where ever. So they are sort of discriminated in many different ways. But there the kind of services they are providing and .... In the village area - to replace them is not possible. And they will not be replaced for a long time. And so we got to work with them. And we saw their clientel or sort of visitors they have been treating, that we saw, but there was another strategy we have done here in Kathmandu itself in the late 1980s when I had started my out-patient at Teaching Hospital. Teaching was just built when I established my outpatient, so but there was a medical anthropologist from the University of Bristol, an Italian lady working there. So, there was a traditional healer in Kirtipur - I hope he's still there. In Kirtipur as a traditional healer and he sees lots of mental patients. And that time only two psychiatrists - one was Mental Hospital one was, I had just started Teaching Hospital psychiatry - only two places in the late 1980s, 1987/ 88 that time. And the number of patients used to be seen much more there than what we used to see together, you know in the hospitals. Many of the mental patients used to be taken to these persons and we did compare the patients going to him and coming to us and we saw a similar sort of diagnostic strategies. And sometimes patients that time were seen by us also, seen by him also - our own patients used to be found in his place also. Almost 85 - 90% of the patients who came to us, they had a consultation before - from a traditional healer. This sort of things we found. And.. this was in Kathmandu, I'm talking, but in village level much more, much higher, almost everybody. So there, there we categorized illness into two or three different categories, psychiatric categories. One sort of illnesses what we said that's those where the role of medications is dominant, like epilepsy, like cases of psychosis where anti-psychotic medicines have to be given, like depression with anti-depressions, this sort of things, like brain delirium or this sort of things. So those categories of illnesses where medicine has to be given, one category. Another category where the role of medicine is nil, like most of the stress-related disorders, affective disorders, hysteria, dissociative disorders .... Very common: hysteria is almost managed in Europe, but it is quite common here!

C&M: You told us the last time it is very common here...

Prof. Dr. M. Nepal: And so, there the role of medicine is minimal, there the role of psychological input is quite high. So, some categorize illnesses in these categories. So there's categories of illnesses where medicine is the main source of treatment, there's categories of illnesses where psychological intervention is the means of treatment, not the medicines. So we oriented them, we developed a manual, an orientation programme for them. Many of them were uneducated. Mohan Rai, Mr. Rai speaks English and is literate, many of his colleagues will not be the same... they can't even read and write, forget about European or English languages. So, we interacted with them and then we taught them that, if you have patients of this sort, you know, then send these patients also to the health post, nearby health post, where paramedics have been trained to identify epilepsy, to provide anti-epileptic medicines, identify psychosis, give anti-psychotic medicines.. like that. But if you have hysterical disorders, affective disorders, don't send these patients here. You just manage on your own. The only thing you do, you don't extract too much money from the family. Don't try to make a lot of money out of them and don't try to abuse the patient. Sometimes, you know, they burned the patient, they do all sorts of things, physical damage to the patient's body. Don't do that: beating, heating, nailing, burning - these sorts of things don't do, don't extract too much money. You just manage on your own. And those patients in which epilepsy is there send these patients here, anti-epileptic medicines have to be given. And: it worked very well!

So, in many places like this old, 60 - 70 years old shamans, they don't know medical signals, but they could differentiate between epileptic features and hysterical features and as medical student - you are medical student or a doctor? - it is so difficult to differentiate for medical students between hysterical features and epileptic features. It is the favourite question I ask to my students in the exam, even to my postgraduates: how do you differentiate between epilepsy and this. And they have difficulties, because they don't have experience and they haven't seen many cases, but these shamans in villages, since they have seen many cases by experience, so they could differentiate this is that case. This sort of patients, when we give our treatment, they respond, but patients with a seizure disorder, epilepsy, they don't respond with our things. They say that. Name they cannot take. You know, this I discovered, it was very surprising to me. And, okey, so these patients should be send to the health post and these patients will be given anti-epileptic medicines, if the patient has hysterical thing only, you just manage on your own....Like, and their management is much better than our management, in medical issue. In our management we do psychotherapy, all kinds of psychotherapy, counseling, takes long time, a lot of money has to be spend, if you take Freudian Psychoanalysis this will take 5 years of treatment. For all that, 2 or 3 consultations they [shamans] will do, the person becomes alright. They will say, okey, this goddess is unhappy with you, I'll do this kind of "puja", and I'll have to sacrifice this chicken, it costs you around 50 rupees, and this goddess, she will become happy....And after 2 or 3 consultations the person is fine - finish! - and a symptomatic relief is there, the person and the whole family feels better. But if that person comes to our side, then we'll do all sorts of investigations: CT-scan, EEG, and then psychotherapy counseling takes long time, takes a lot of money. So, if they are doing that kind of job with the same sort of result, why not they should continue doing that? And it worked very well in that way, in epileptic patients refering to this side, they are on anti-epileptic medicines, patients with psychosis, okey, they'll start with anti-psychotic medicines. In our programme we had 5 basic medicines: phenobarbital tablet only that for epilepsy, chlorbromazine tablet, amitriptylin tablet for depression, chlorbromazine for psychosis..., like the basic medicines used to be given. It was all given free of cost as part of the programme. So, it was working, so this was the experience which I think I was sharing with you the last time also and you know, there is, for many years to come, these villages will not have the services of psychotherapists or psychiatrists. Maybe hundred years, maybe hundred, two hundred years..so by then they will still be providing services, so instead of replacing them, throwing them out or saying them they are useless people and this, we should work in collaboration with them and in that way we can provide better services. That's what we concluded.

C&M: Has there been any attempt to train traditional healers in the line of other departments like obstetrics or internal medicine, like for different kinds of diseases or problems?

Prof. Dr. M. Nepal: Not so much, not so much, this is an interesting question...

C&M: Mostly psychiatric?

Prof. Dr. M. Nepal: Psychiatry we have used them as therapists, but they have been used as, more as a messenger or health education people for this rehydration solution, nun chini pani, that solution, advertisement of that, they have been used as a messenger. In some places for tuberculosis programme, identification of tuberculosis in the villages, they have been used in the eastern part of Nepal, as part of, I think the British-Nepal Medical Trust has used them. In some places maybe for family planning and other programmes they have been used. But our sources that if we, we used them more as a colleague. Other programmes, they use them more as agents of change, you know, because they were so popular, so powerful, so they could just spread the message. But we used them as an equal therapist. Do you see the difference? But this is an interesting question.

C&M: What is your opinion on the consciousness of biomedics here in Nepal upon the other alternative healing systems that exist. Is there any attempt to collaborate, e.g. I'm working in surgery here. I don't think the surgeons are very much interested in collaboration or even conscious about what happens in the village area and how traditional healers try to deal with the problems in village level.

Prof. Dr. M. Nepal: It is another interesting question. It depends upon the training and the background of persons involved. That of course is there. So surgeons are more a mechanical kind of speciality as you know. So, for them it will be less. Even in the psychological aspects of the patient care they have a minimum kind of experience or knowledge about that. They are all mechanical: okey, this and that sort of thing is it, this has to be removed, this has to be replaced - that kind of mechanical mind they have. But in general, it's not there. There's one question, it's of stigma. Stigma, you know, these people are uneducated, illiterate village people and if we try to relate ourselves with these people then it's not so good, you are considered again low.

C&M: So it's not considered as a resource or...

Prof. Dr. M. Nepal: I'm trained in Germany, and so why should I talk with these illiterate people. That kind of stigma is there quite a lot. Other prejudices not so much. But, you know, biomeds, you know this is an interesting question on other sides, you people are coming all the way from Germany getting interested in this and asking all these questions. Here, you know, this tradition of alternative medicine and complementary care these exist. These are the originators of this system in the world, this part of the world. But it is completely neglected. It is completely banned. These people are more towards the western side, more mechanical, more modern, so-called modern kind of approach they are going on and this part is ignored, overlooked completely. And it's not considered modern or development, if I start talking about this sort of things my colleagues will think that I've gone either crazy, mad myself or they'll think that I'm talking about non-development, I'm not trying to develop psychiatry myself. But once you come, people from Germany will come and ask me these questions, they'll say "Oh, this is very important, because people from Germany also are interested in this!". That kind of attitude. But there is, a good blend has to take place. Biomedicine has some advantages, good things. This alternative, complementary medicine has certain advantages, certain good things. And what patients need, what societies will need: best of the two things. You know, if something is working here, if it is better on this side, why not to take it? There is good on this side, why not to take it? Whatever patient care, care of the patient is, it's the best of the two worlds what we need, not thinking of this is, this comes from rural area, this comes from the illiterate part of society, this comes from lower caste group. No! It is working, it's worth. It has to be blended. So that are the rules to be there and I was talking to my colleague, the Dean of the Institute of Medicine, we were talking earlier here, and he was saying that he is reading through all these books on psychology and all he had red when he was student age, and now he is reading again and he is finding it very interesting. He's a pediatrician. And, we were talking in that way, that in Nepal and in this part of the world nowadays, you know, there is a lot of Yogis, practitioners have become very famous in this. There is one called Ram Deva. Have you heard of him? He gives, in the television he gives programmes. Millions of people in India they are taking this, many in Nepal also, many of my patients, many people I know, not patients, even other persons also. All my days have changed, knowing I'm getting right up, I'll talk in the morning, and one hour lying in front of television seeing Yoga and I'll do this..

C&M: I know this...

Prof. Dr. M. Nepal: You saw this?

C&M: Yes, a friend of mine, actually a German, too, sits in front of the TV in the morning sometimes.

Prof. Dr. M. Nepal: Many Nepali people tell me like that, many of my patients. And he teaches this and that, ... and I feel much better now and healthy. And he is extreme, Ram Devas views. He says they'd throw off their medicines, blood pressure medicines, depression medicines and other medicines, you don't need medicines at all. Practically, it's another extreme. So, and he has become very, very popular, extremely popular in a short span of time: Within the last one year, two years! He's such a popularity, because of the media also, television, satellite television these days it goes a lot of places and people see it and ... So the popularity of these people and the effectivity of their methods is an alternative approach. It is primarily stress-related problems, psychological things which he's handeling, and then he's providing emotional support. He's providing counseling through the television channels to a large number of people. And people are getting better, they are feeling better, which was not being provided by these surgeons we were talking about, these physicians we were talking about. You go to cardiology, cardiologist I think are so mechanical, you know they do ECG, Echo, this, that, heart problems, this that, but they'll not think of the psychological aspect, the mental health aspect of heart problems. They'll not think. Psychological aspects for them, once they think of mental health, it means only hardcore psychiatric, schizophrenia, manic-depressive or those sorts of things considered psychiatric. The milder form of things is not considered psychologically ill. But it's widespread, it's very widespread and people are getting, this sort of people are getting better, they used to be feeling sick, but they are feeling better nowadays. Even in the mental health, in large epidemiological surveys, done in many countries, in our country also it was done. Almost, I remember, 42 or 45 percent of the German population they have identifyable mental health problems; and lots more here. Almost 45% of the German population, this survey was done 2 years or 3 years back, observation in psychological medicine. Okey, that's a huge number. And this years in the June month, the month of June, in America, a survey of a similar subject was published which said that more than half of the Americans, more than half, they had an identifyable mental health problem. Similar method, the German survey and the American survey was done similar method. They have identifyable mental health problems. So, you know what happened in America? For two days or three days all the major newspapers had headlines that half of the Americans are mentally ill, the large (???). And mentally ill means, again misconception is people think metally ill means people are psychotic, crazy, mad - this is not true! There are sort of softer psychological illnesses: stresses, anxiety, depression, this sort of things. And those things are not easily identified also. The person who is suffering, he or she also cannot complain, he also will not know what is happening. There's no biological test, there's no x-ray, there is no scan, there is no blood test or there is no blood pressure test, like this. So these people keep on suffering, they keep on going to the doctors, not knowing what is happening. So these are the people who are getting benefits from this - you know alternative methods of treatment. And all of them are checked, as the villagers in my project, all of them will not require medicines. All of them will not require surgery. They will be alright with simple counseling, with emotional support and simple psychological techniques which Ram Deva is providing through the, from the "idiot box".

C&M: Yes, every morning...

Prof. Dr. M. Nepal: Every morning. Maybe you ask one question more and then we meet again.

C&M: Yes, that's no problem. Maybe you could give an outlook to the future what you expect like for the situation here in Nepal. Is it possible that more and more biomedical doctors get involved in projects like the one you are doing? With a consciousness of having lots of traditional healers around that could help to establish a nationwide medical health care system.

Prof. Dr. M. Nepal: It has to be done. But people recognize the role of psychological factors in the health, that part is being recognized day by day. That is an amazing thing to see. In front of my eyes things are changing. Many things are changing. I had not dreamt when I had come here, as a psychiatrist trained in India, I came here to start a Department in Teaching Hospital, in 1986. That time, I had not thought that things will change so rapidly, so fast. But this is happening, this is a very positive, very good thing. In Nepal also this is happening. So change is possible, even in Nepal! That's what I say.

C&M: That's the quotation we have in the medical library..

C&M: But this only can work after you showed the westerners how this can work, like shamanism, because they came here to learn about shamanism and then do this in Germany and then it's ... people are getting more interested in stuff like this, because they can reach it in Germany also, they don't have to travel to Nepal.

Prof. Dr. M. Nepal: Yes, that is my quotation. I always give that quotation, so when I was the director of the hospital, I was the director earlier, so my quotation was picked up. So in front of my eyes things have changed. So, it is possible to bring in changes, but this actively involving traditional healers in the treatment process, that needs to be done by someone. At the moment not too many people are doing it. So, but at certain points of time, few people will recognize that need. But actively people are not doing it. But I was surprised, in the western countries like Germany or America, the interest in alternative medicine increased. That again will come back here. That will come back here as well. So there«s a doctor in Germany, he does treatment with both the things, he does modern medical treatment also, he does this shamanism also. So Nepali doctors also will start doing that, start practising that. So in a way, it has gone to the West and come back. And the West again is a kind of leader - role models who«ll show us the path.

Prof. Dr. M. Nepal: These things were established thousands of years back here. And then in between the importances of these things were lost, we lost the contact and touch with these things. And these people have started rushing towards western things, things which were much more materialistic and it«s like that. And now that reconnection has to be made. And you need a strong leader for that, really strong, whether I«ll fit for that I doubt!

C&M: And you see the way goes through the western side, so first it goes to the west and then it comes back, like a re-import to Nepal? Even though the source of all of this alternative medicine has originally come from Nepal...

Prof. Dr. M. Nepal: Yes, it was for around 2000 years, like Indians say in India. Our Nepal was a small country, so this part of the world remained as ah.. colonized by outside forces. So since the last 2000 years these things happening are happening. And as a result, people have lost their confidence in their ability, their potential that we could also do something new. You know that lack of confidence, that they are completely disempowered, because of they have sort of subdued.... earlier by Muslims, earlier by other sorts of invaders then Muslims, like Hindus, Aryans they call it. You know the Aryans? Hitler used it in a bad way. But they call Aryans, so Hindu Aryans are not that Hitler-way, but in a different way. But they were subdued for the last 2000 years. Then while the British came, and there was lot of in-fighting and the caste system that developed in an upper, higher caste and a lower caste. You know, the Hindu caste system: four caste systems, the Brahmins, the Kshatriyas, the Vajshyas, Shudras and the Untouchables. So, they started fighting amongst each other. Whereas, you know, the Muslim religion came and Christianity came, where everyone is equal, where everyone could go everywhere. So, those were sort of revolutionary ideas, which were picked up very fast. Whereas the old Hindu Aryan tradition, you know, started fighting with each other. So they were subdued, they lost the battles and they were subdued for 2000 years. And as result of that they have lost that confidence that we could do something on our own and we should work. In my thinking that is the reason. So it has to go to the west and then is has to be re-imported. But change is possible even in Nepal!!!

C&M: Thank you very much.

1.2. Dr. R. P. Gartoulla, Dep. of Public Health, TUTH, Kathmandu

Interview questions for Ass. Prof. Dr. R. P. Gartoulla, answered by e-mail in November 2005:

 

Q: Could you just introduce yourself and give a brief summary on the topics you are interested in in medical anthropology?

A: I have been involved in this field since 1984. First, I started doing research and then teaching to medical, public health and nursing graduates and postgraduates, supervise thesis of bachelor, master and Ph.D. students.

Q: What are the causes for patients to seek help either with a shaman or with a biomedical doctor?

A: The term "patient" is not suitable everywhere. The term should be used in a hospital after havingproper diagnosis (not symptomatic) with pathological and radiological (where applicable) probing and given treatment with drugs and/or surgical cases.You may use the term as "users/consumers" visiting either to shaman healers or health professionals. They go to shaman healers because:

  • · They have long term relationship
  • · Mostly local
  • · Culturally same group
  • · Low cost
  • · Easily available
  • · Meet on time
  • · Simple way of curing
  • · In the same religious background
  • · Kin relationship
  • · Faith

No taboos on shamans ingredients (see the book entitled Therapy pattern of conventional medicine...available at TUTH library and also see Quest for Health available at library and in the market) People generally go to health institutions after the advice of shaman healers. Very few directly go to health institutions because of belief, cost and previous experiences.

Q: Which role does the income of the family, social status, caste, age, sex and religion play for this decision?

A: Generally, culture plays vital role for the decision of consultation and medication. Income, social status and demographic status determine for the decision process. The cost of health institutions is not bearable to the poor is an important phenomenon to push towards shamanism. Gender is another factor for pushing to shamanism because, mostly the male as an active income generator of the family will get proper medication even though that is costly.

Q: What are the main questions why people seek help with a shaman? Or any other alternative medical practitioner?

(See answer of no 1 question)

  • · Cure rate
  • · Availability
  • · Low cost

Etc

Q: Do you think both approaches on disease (sickness) and health - the biomedical and the shaman's way - are influencing each other? What could be the synergism coming out of this co-existence? Has there been research on this special question?

A: There is very few research which is not sufficient. Only after promulgation of Tenth Five Years Plan it has given priority for coordination of both services. The government level do not have action plan to integrate both fields. Medical practitioners do not wish to be with shaman healers and there is the problem of recognition of shamanism among the medical personnel. I don't see any co-existence between two practices.

Q: Do you think it's possible to implement traditional healers in the national medical system to guarantee a country wide access to health facilities? (E.g. Mental health in communities managed by Jhankris.) How do you think implementing could be done? Has there been any effort for this so far?

A: It would be very nice to integrate THs in National health stream. But, miserably it has not been started yet. THs are the first front line health manpower in all strata of the country, but the government policies are silent on this. The policy makers and NGOs do not understand the truth. THs are the most institutions to provide health care, but are out of training and linkage.

Q: Is there consciousness about the existence of alternative healing methods within the biomedical structures in Nepal? Do biomedical doctors take it into account?

A: I don't think it is so.

Q: Do both, the biomedics and the alternative healers, see the limitation of their own approach to illness/sickness and health?

A: Yes absolutely they see, but separately. There is no coordination and networking between them.

Q: Overlooking the past 10 years, did you find major changes in the way patients chose their healers or in the consciousness of biomedical doctors and shamans about each other?

A: The populations with exposure by the CBOs, NGOs and FCHV, TBA have changed health seeking behaviour. Now a days they contact to biomedical institutions where NGOs are working, but still they go to shaman healers first and only then to health institutions.

Q: What is the present situation? What are you expecting for the future?

A: Even though the modern health facilities are available, people do not go to health facilities directly. More than 50% of the population do self medication. (see o Google search type "Ritu Prasad Gartoulla" you will get self medication)

Q: What about other possibilities for alternative health care like Ayurveda, Unani, etc.? How do they influence both, the biomedical and the shamanic treatment?

A: The possibilities for alternative health care like Ayurveda and Unani are like allopathic medicine which has certain standards to follow for receiving and giving treatment/medication. They are the developed form of Ethnomedicine and are common and popular.

Q: Are there any culture bound syndromes in Nepal? (E.g. Susto in Latin America.) How are they dealt with and how are they described by the anthropologists?

A: The feeling of supernatural being (see the book on Medical Anthropology written by ...?? Published from UK..) and personalistic and naturalistic etiologies. (see the book on An introduction to Medical Sociology and Medical Anthropology available at TUTH library/Nursing library Maharajgunj). Ethnopsychiatry is the example in Nepal where THs heal/treat through chanting till the problem is not removed. There are several examples of culture bound syndromes (see Therapy pattern of conventional medicine and also Quest for Health).

Q: Further literature ...?

A: Go through above mentioned three books for literatures and Google search.

Q: New edition of an Introduction to Medical Sociology and Anthropology?

A: I am going to correct the manuscript to publish the second edition within 6 months probably.

Thank you.

Tables

 

TABLE 1. The following figures serve to illustrate the social situation in Nepal (Tiwari 2005)

population

23.151.423

density of population

157 persons per km2

number of households in per cent in

 

rural areas

83.90 %

urban areas

16.10 %

population growth rate

2.24 %

annual per capita income

235.00 US $

Literacy rate

54 %

Men

65 %

Women

43 %

Life expectancy at birth

62.2 years

Total fertility rate/woman

4.1

Death rate of mothers at birth/100.000 life births (1996)

539

Death rate of children at birth/1000 life births

64.2

Death rate of children under 5/1000 life births

91

Access to drinking water

71.6 %

High quality drinking water

4.4 %

Medium quality drinking water

6.4 %

Basic provision with drinking water

60.8 %

 

TABLE 2. Health Services Coverage Fact Sheet 1

REPORTING STATUS

1999/00

2000/01

2001/02

District to MIS Section

100%

100%

100%

Hospital to DHO

61%

75%

80%

PHCC to district

96%

96%

96%

HP to District

95%

97%

97%

Sub Health Post to HP/PHC

92%

94%

94%

FCHV to SHP/HP/PHC

55%

58%

61%

TBA to SHP/HP/PHC

51%

51%

53%

NGO Private Sectors/Others to DHO

63%

58%

70%

EXPANDED PROGRAMME ON IMMUNISATION

 

 

 

1 BCG Coverage

97%

95%

94%

2 DPT-3 Coverage

80%

80%

80%

3 Polio-3 Coverage

80%

80%

80%

4 Measles Coverage

77%

75%

76%

5. Number of children <5 Years Received Polio (NID-Phase 1)

3,632,031

3,949,544

4,116,535

Number of children <5 Years Received Polio (NID-Phase 2)

3,808,542

4,012,559

4,126,782

NUTRITION Growth Monitoring

 

 

 

6 Growth Monitoring Coverage as % of <3 Children New Visits

34%

38%

31%

7. Promotion of Malnourished Children (Weight/Age-New Visits)

21%

18%

16%

ACUTE RESPIRATORY TRACT INFECTION

 

 

 

8 Reported incidence of ARI/1,000 <5 children New Visits

166

210

229

9 Annual Incidence of Pneumonia (Mild+Severe)/1,000 among <5 Children New Visits

72

90

97

10 Proportion of Severe Pneumonia among New Cases

5.3

4.2

3.8

 

TABLE 3. Health Services Coverage Fact Sheet 2

DIARRHOEAL DISEASES

 

 

 

11 Incidence of Diarrhoea/1,000 <5 Children New Cases

164

177

177

12 % of Some Dehydration among Total New Cases

41.1%

41.7%

41.6%

13 % of Severe dehydration among Total New Cases

5%

4%

4%

14 Diarrhoeal Deaths /1,000

0.7

0.1

0.04

15 Case Fatality Rate/1,000

0.4

0.4

0.22

SAFE MOTHERHOOD

 

 

 

 

 

165 First Antenatal Visits as % of Expected Pregnancies

35%

41%

43%

17 Average No. of ANC Visits per Pregnant Woman

1.7

1.8

1.9

18 Deliveries Conducted by TBA as % of Expected Pregnancies

5.3%

6.5%

7.1%

19 Deliveries conducted by trained person (Including TBA's) as % of expected pregnancies

13.5%

13.8%

15.0%

FAMILY PLANNING

 

 

 

 

 

20 Contraceptive Prevalence Rate (CPR)

34.5%

36.9%

37.4%

21 Condoms (CPR Method Mix)

1.9%

2.1%

2.2%

22 Pills "

2.3%

3.0%

2.6%

23 Depo Provera "

8.7%

9.7%

10.2%

24 IUD "

0.7%

0.8%

0.8%

25 Norplant "

0.8%

0.8%

0.8%

265 Sterilisation "

20.0%

20.5%

20.9%

27 Couple Years of Protection (CYP) By Method (% of MWRA) for New Acceptors

32.6%

34.1%

33.6%

28 Condoms (CYP Method Mix)

1.9%

2.2%

2.2%

29 Pills "

1.2%

1.4%

1.5%

30 Depo "

6.1%

6.8%

7.2%

31 IUD "

1.5%

1.6%

2.1%

32 Norplant "

1.0%

0.9%

0.7%

33 Sterilisation "

20.7%

21.3%

19.8%

MALARIA CONTROL PROGRAMME

 

 

 

 

 

34 Blood Slide Examination Rate per 100 Malarious Area Population

0.6

0.7

0.6

35 Slide Positivity Rate (SPR)

8.9

5.4

9.2

TUBERCULOSIS CONTROL PROGRAMME

 

 

 

 

 

* 36 Case Detection Rate

67%

69%

70%

* 37 New Sputum +ve

13,446

13,683

13,714

*38 Treatment Success Rate on DOTS

89%

89%

89%

*39 Sputum Convertion Rate

84%

84%

84%

*40 DOTS Coverage (Population)

75%

84%

89%

LEPROSY CONTROL PROGRAMME

 

 

 

 

 

** 41 New Case Detection Rate/10,000

3.18

3.44

5.73

** 42 Prevalence Rate/10,000

3.88

3.43

4.41

** 43 Disability Rate Grade 2 Among New Cases

7.18

8.43

4.31

CURATIVE SERVICES

 

 

 

 

 

44 Total OPD New Visits

7,036,459

7,846,667

8,642,852

45 Total OPD New Visits as % of Total Population

30.7%

33.4%

35.8%

Source: FHD, PFAD/DoHS, 2002 * NT, ** NTC, ** LCD, N/A: Not Available Kandel D 2003 10 02 The past and present health system of Nepal; www.asiatraditionalmedicine.it/archivio/file/000/schede/Kandel_D_2003_10_02_The_past_and_present_health_s ystem_of_Nepal.doc ; Retreived 21.02.2006

FIGURE 13. DoHS Annual Report 2001/2002: Organisational Structure of the Department of Health Services

FIGURE 14. Information broschure Shamanistic Studies and Research Centre, Naikap Page 1

FIGURE 15. Information broschure Shamanistic Studies and Research Centre, Naikap Page 2

Glossary of Nepalese terms

A

Amchi: Tibetian herbal healer

ankat herne: rice diagnosis

Ayurveda: the knowledge of long life, old Hindu tradition of healing

B

Baidang: shaman who does not enter trance state and only uses Jharpuk for diagnosis

Ban-Jhankri: original shaman

Bayu: spirit of wind and air demanding to be accepted into the circle of ancestor spirits

Bell mala: necklace made of bells, worn by shamans in healing ceremonies

Bhairab: deity representing the southern sphere in Nepali shamanistic cosmology

Bhuta: spirit of a person who died of unnatural causes

Bijuwa: Rai word for shaman

Bokshi: witch

Brahman: highest caste in Nepalese Hinduism

C

Chang: rice beer

Chhetri: second-highest caste in Nepalese Hinduism

Chinta: shamanistic healing ritual

chiso: cold

D

Devi: goddess

F

Fedangwa: term chosen by the Limbo for a subgroup of their shamans

G

gharmi: hot

Ghat: cremation site

Graha bigrayo: unfavourable constellation of planets

J

Janne Manche: ,people who know"; these are the ,wise" persons in a (village) community, e.g. elders, but also village teachers or healers

Jhankri: shaman

Jharphuk: short healing ceremony comprising mantra and removal of negative energies through passing hands over a patient

Jharpukey: healer who does not enter trance state and only uses Jharpuk for diagnosis

Jokhana: oracle used by shamans for diagnosis

Jungali: queen of the forest; she plays a significant role in the cosmology of Nepalese shamanism

Jyotishi: Hindu astrologer

K

khadco kattne: ritual of cutting the lines of fate

Khukuri: Nepalese knife

kubidhy: bad knowledge, knowledge employed with evil intention

Kuladeva: ancestor spirit

L

Lagu: general term for evil spirits

Lama: Buddhist scholar

Limbu: ethnic group in Nepal

M

Mala: necklace

Mangba: member of a subgroup of Limbu shamans. Specialist for haunted souls of persons who died from violence or at birth

Mantra: prayer formula

Masaan: certain type of evil spirits

N

nadi herne: pulse diagnosis

Naga: snake, snake god

Nun chini pani: oral rehydration solution

O

Ojha: shaman who is considered an expert for particularly serious acute or chronic disorders

P

Phombo: Jirel word for shaman

Phurba: ceremonial dagger, ritual object used by Nepalese shamans

Pret: evil spirit

Puja: worship

Pujari: priest, i.e. person who performs the Puja in a temple

R

Rai: Tibetian-Nepalese ethnic group in Nepal

Rithamala: necklace made from seeds of the soap nut

Rudrakshamala: necklace from rudraksha seeds

S

Saano: small

Samba: member of a subgroup of Limbu shamans. He is an expert in Mundhum, the oral traditions and mythologies of the Limbu

Shikari: the hunter, plays an important role in shamanistic cosmology in Nepal

Subidhy: good knowledge, knowledge employed in a positive sense, e.g. in healing

T

Tamang: ethnic group in Nepal

U

Unani: Arab healing tradition that reached Nepal via India and is based on the homoral pathology according to Galen

V

Vaidhya: Ayurveda practitioner

Y

Yeba: member of a subgroup of Limbu shamans. He is an expert in diseases attributed to supernatural causes

Yema: female form of Yeba

 

4. References

Ayurvedic Foundations (2006) What is Ayurveda? Retreived 16.02.2006 from www.ayur.com

Ärzte Zeitung (03.06.2004) Lebenserwartung in Deutschland nimmt weiter zu; Retreived 25.03.2006 from www.aerzte-zeitung.de/docs/2004/06/03/102a0502.asp

Beine, Dave (2001) Saano Dumre revisited: Changing models of illness in a village of central Nepal; in: Contributions to Nepalese Studies; Vol. 28; No. 2; 155-185; Kathmandu

Benedikter, Thomas (2003) Krieg im Himalaya - Hintergründe des Maoistenaufstandes in Nepal -Eine politische Landeskunde; Politikwissenschaft Band 97; LIT; Münster; Hamburg; London

Blustain, Harvey S. (1976) Levels of medicine in a central Nepali village; in: Contributions to Nepalese Studies; Vol. 3; 83 - 105; Kathmandu

Böker, Heinz (1992) Concepts of mental illness: an ethnopsychiatric study of the mental hospital«s in- and out-patients in the Kathmandu valley, in: Contributions to Nepalese Studies; Vol. 19, No.1; 27 - 50; Kathmandu

CIJ - Centre for Investigative Journalism (2004) People in the `People's War'; Himal Books, Lalitpur, Nepal

Davies, Marcus (1994/95) Modern and Traditional Medicine in the Developing World; in: Latitudes - The Mc Gill Journal for Developing Studies; Vol. 4; Mc Gill University Montreal, Quebec, Canada; Retreived 4.02.2006 from www.ssmu.mcgill.ca/journals/latitudes/volumes.htm

Dietrich, Angela (1996) Buddhist healers in Nepal - some observations, in: Contributions to Nepalese Studies; Vol. 23, No. 2; 473 - 480; Kathmandu

Dixit, Hemang (1999) The Quest for Health; Educational Enterprise (P) Ltd; Kathmandu; Second Edition

Donner, Wolf (1990) Nepal. Beck'sche Reihe, Aktuelle Länderkunden; München

Dougherty, Linda M. (1986) Sita and the Goddess: A Case Study of a Woman Healer in Nepal; in: Contributions to Nepalese Studies; Vol.14; No.1; 25 - 36; Kathmandu

Durkin-Longley, Maureen (1984) Multiple therapeutic use in urban Nepal; in: Social Science and Medicine; Vol. 19; No. 8; 867 - 872

Eigner, Dagmar (1998) Struktur und Dynamik schamanischer Heilrituale in Nepal; in: C. Gottschalk-Batschkus (ed.) Curare Sonderband 14/98 Ethnotherapien. (p. 66-69) VWB-Verlag für Wissenschaft und Bildung; Berlin

Gartoulla, Ritu Prasad (1998) Therapy pattern of Conventional Medicine with other alternative medications - A study in medical anthropology in Nepal; Research Centre for Integrated Development, Kathmandu

Graner, Elvira (2005) Kartoffeln und Nepalis - Subsistenz-Ökonomie und internationale Migration; Nepal Information Nr.95; Juli 2005

Green, Edward C. (1988) Can collaborative programs between biomedical and african indigenous health practitioners succeed? In: Social Science and Medicine; Vol. 27; No.11; 1125 - 1130

Hackenbruch, Elgin (Hrsg.) (1998) Going International - Pflegende in der Entwicklungszusammenarbeit und Humanitären Hilfe; Ullstein Medical

Haddix McKay, Kimber (2002) Health needs in two ethnic communities of Humla District, Nepal; in: Contributions to Nepalese Studies; Vol.29; No. 2; 241 - 273; Kathmandu

Himalayan Amchi Association; Sienna Craig Introduction to traditional amchi medicine. Retreived 16.02.2006 from www.drokpa.org/haa.htm

Hitchcock, John T.; Jones, Rex L. (1976) Spirit Possession in the Nepal Himalayas; Vikas Publishing House, Reprint 1996

Jones, Rex L. (1976) Limbu Spirit Possession and Shamanism; in: Hitchcock, John T. & Jones, Rex L.; Spirit Possession in the Nepal Himalayas; 29 - 55; Vikas Publishing House, Reprint 1996

Kleinman, Arthur (1978) Concepts and a model for the comparison of medical systems as cultural systems; in: Social Science and Medicine; Vol. 12; 85 - 93

Kleinman, Arthur (1981) Patients and Healers in the Context of Culture - An Exploration of the Borderland between Anthropology, Medicine and Psychiatry. University of California Press; Berkeley, Los Angeles; London

Kristvik, Ellen (1999) Drums and Syringes; Bibliotheca Himalayica; Series III; Vol. 7; Kathmandu

Ludwig, Bruni; Pfleiderer-Becker, Beatrix (1978) Materialien zur Ethnomedizin; Spektrum der Dritten Welt 15; Hrsg.: Wilfried Euchner; Kübel-Stiftung gGmbH, Bensheim

Molesworth, Kate (2006) Community Action for Health in Conflict; in: Bulletin von Medicus Mundi Schweiz Nr. 99; Januar 2006; Retreived 22.02.2006 from www.medicusmundi.ch/mms/services/bulletin/bulletin200601/kap02/Moleswort h.html

Müller-Ebeling, Claudia; Rätsch, Christian; Shahi, Surendra Bahadur (2000) Schamanismus und Tantra in Nepal - Heilmethoden, Thankas und Rituale aus dem Himalaya. AT Verlag; Arau, Schweiz

Okada, Ferdinand E. (1976) Notes on two shaman-curers in Kathmandu; ; in: Contributions to Nepalese Studies; Vol. 3; 107 - 112; Kathmandu

Peters, Larry G. (1979) Shamanism and Medicine in Developing Nepal; in: Contributions to Nepalese Studies; Vol. 6; No. 2; 27 - 43; Kathmandu

Pfleiderer, Beatrix; Bichmann, Wolfgang (1985) Krankheit und Kultur - Eine Einführung in die Ethnomedizin; Dietrich Reimer Verlag; Berlin

Poudyal, Bimal (1997) Traditional Healers as Eye Team Members in Nepal; in: Community Eye Health Journal; Vol. 10; No. 21; 4 - 5

Rätsch, Christian (2000) Die Zukunft des Schamanismus; in: Müller-Ebeling, Claudia; Rätsch, Christian; Shahi, Surendra Bahadur; Schamanismus und Tantra in Nepal - Heilmethoden, Thankas und Rituale aus dem Himalaya; AT Verlag; Arau, Schweiz

Reinhard, Johan (1976) Shamanism and Spirit Possession: The Definition Problem; in: Hitchcock , John T. & Jones, Rex L.; Spirit Possession in the Nepal Himalayas; 12 - 20; Vikas Publishing House, Reprint 1996

Shankar, P. Ravi (2001) A study on the use of complementary and alternative medicine therapies in and around Pokhara sub-metropolitan city, western Nepal; Pokhara; Internetrecherche, Retrieved 21.01.2006 from http://clinmed.netprints.org/cgi/content/full/2002050007v1

Sidky, H.; Spielbauer, Ronald H.; Subedi, Janardan; Hamill, James; Singh, Robin; Blangero, J.; Williams-Blangero, S. 2000: Phombos: a look at traditional healers among the Jirels of eastern Nepal; in: Contributions to Nepalese Studies; The Jirel Issue; 39 - 52; Kathmandu

Starke, Wolfhard (2005) Eine Alternative zum Vorruhestand - Als Unfallchirurg in Nepal; in: Deutsches Ärzteblatt; Jg. 102; Heft 31 - 32; 8. August 2005

Stone, Linda (1976) Concepts of Illness and Curing in a Central Nepal Village; in: Contributions to Nepalese Studies; Vol. 3; 55 - 80; Kathmandu

Stone, Linda (1983): Hierarchy and food in Nepalese healing rituals; in: Social Science and Medicine; Vol. 17; No. 14; 971 - 978

Stone, Linda (1986) Primary Health Care for whom? Village perspectives from Nepal; in: Social Science and Medicine; Vol. 22; No. 3; 293 - 302

Subedi, Madhusudan Sharma (2001) Medical Anthropology of Nepal; Udaya Books; Kathmandu

Tiwari, Dipak Prasad; Kandel, Saroj Prakash (2005) Health Data and Facts Sheet with quick review of health; Institute of Medicine, TUTH; Kathmandu

Tiwari, Dipak Prasad; Kandel, Saroj Prakash (2006) Traveliteindia Unani System of Medicine; Retrieved 16.02.2006 from www.traveliteindia.com/healing1.asp

United Nations (2004) Nepal Human Development Report 2004

WHO; Maria Paalman (2004) Towards Pro-poor Health Planning - In the Context of Macroeconomics and Health; Country Case Study Nepal; Royal Tropical Institute Amsterdam

Young, Allan (1983) The relevance of traditional medical cultures to modern Primary Health Care; in: Social Science and Medicine; Vol. 17; No. 16; 1205 - 1211

Gratitudes

I want to express my gratitude to all persons involved immediately in the generation of this publication: to the Ethnomed team for the wonderful time I spent in Munich in further education , for the unusual experiences and encounters. I found the right track in my life, many pieces of the puzzle suddenly fit in - thank you! In particular I wish to mention Florian Rubner who always had valuable suggestions, who endured endless discussions and answered all questions with equanimity; Jörg Fachner, Gerhard Tucek and Christian Rätsch who turned my concluding colloquium into a new start with their ideas and comments, and Andreas Reimers, a physician who shares my interest in Nepal and shamanism.

I thank Prof. Dr. Aldridge for the opportunity to publish this paper and for the in-depth discussion prior to publication, and Christina Wagner for her translation.

I also thank the Evangelisches Studienwerk e.V. Villigst ; without their generous support I would never have been able to afford the journey to Nepal nor the Ethnomed course.

My heart-felt thanks go to all others whose active and unflagging support helped me to conclude this paper, specifically Prof. Dr. Nepal and Ass. Prof. Dr. Gartoulla whose willingness to be interviewed and whose publications facilitated my approach to the subject. I would also mention Binod Shresta, who is still wondering why I find the subject so exciting but nevertheless provided organizational backing, and Sudeep who introduced me to the mysteries of the Nepalese language.

I am grateful to Mohan Rai, Suraj, Marion and Shiva for their lessons in shamanism and for the many clarifications, to the wider Rai family and in particular to Chhema and Raj Kumar for making me feel at home. I thank Markus for sharing ethnographic material.

My specific thanks go to the shamans at the Shamanistic Studies and Research Centre in Naikap ; their gift to me is more than I can express in words.

And finally I would like to thank all those people in Nepal I met who helped me to develop a deeper understanding of the small things in every-day life and who permitted me to share their joy and their suffering. They will always have a place in my heart.

In addition I thank my parents and friends for their continuous and tremendous support; without them I would not have been able to cope.

 

Carolin Häußermann

Author details

FIGURE 16. Carolin Häußermann

Study of medicine at University Witten/Herdecke, Germany; Scholar of Evangelisches Studienwerk e. V. Villigst, Germany; finished the study course Ethnomedicine at the Institute for Ethnomedicine in Munich, Germany in June 2006; training in Acupuncture (TCM) at University Witten/Herdecke; medical internships and practice in Portugal, Brasil, Nepal and the UK

Interests:

cultural understanding of health and illness; Synthesis of shamanism and biomedicine in Nepal

This article can be cited as:

Häußermann, C. (2006) Shamanism and biomedical approaches in Nepal -Dualism or Sythesis? Music Therapy Today (Online 1st October) Vol.VII (3) 514-622. available at http://musictherapyworld.net


1. I use this expression "kiranti" also used by Gartoulla, which is to be found in English-language literature. Another version is "Kirati", see e.g. Müller-Ebeling 2000. The Rai are part of the tibeto-nepali group.

2. In Germany average life expectancy is now 81.2 years for girls and 75.4 years for boys (Ärzte Zeitung, June 3, 2004)

3. For statistical data on the social and health care situation in Nepal see appendix.

4. The system to categorize food as either hot or cold - Subedi adds neutral as another category - is by no means consistent, according to studies by Stone (1976), Blustain (1976) and Subedi (2003), in comparison of regions in Nepal and also within ethnic groups (Subedi 2001). But the idea of a hot - cold imbalance as cause of illness is widely held in Nepal.

5. The knowledge held by Bokshis and shamans is almost identical; what is different is the way they use it: witches use it as kubidhya or bad knowledge, shamans as subidhya (good knowledge) (Subedi 2001). Mohan Rai told me god Shiva had given one mantra more to shamans than to witches. Thus shamans defeated Bokshis in a fight because Bokshis were unable to take a bite from the Amaliso leaf (lat. Thysanolaena maxima). The leafs of this plant still show the bite of the witches and are seen as symbols of shaman superiority.

6. Another name for the Evil Eye in Turkey is "Nazar" which may be averted with an eye made of blue glass (Nazar Boncugu) or blue glass perls.

7. I opt for the form used by Mohan Rai, i.e. Bhuta in singular and Bhutas in plural. Stone (1976), Peters (1979) and Gartoulla (1998) use Bhut.

8. Much feared are Bhuta attacks at night and at road crossings where evil spirits are assumed to gather.

9. I use the version Masaan and the plural Masaans used by Mohan Rai and also by Peters (1979). Stone (1976) writes Masan. Gartoulla (1998) uses Masana and the plural form of Masanas.

10. The Rai bury their dead whereas Hindus burn them.

11. A particularly distinct sign, as I was told in Naikap

12. PHC is characterized by the use of local resources, e.g. involvement of locals, and adaptation of intervention to existing socio-cultural and socio-economic conditions in the target group. PHC is seen as a strategy to develop society, to improve living conditions and thereby health of the population. The basic view is that physicians and paramedics can only address symptoms but cannot eliminate the original causes of illness in developing countries, e.g. poverty (Hackenbruch 1998).

13. e.g. a postgraduate university course that is paid in full.

14. Blood analysis indicates changes in electrolyte metabolism, immune defense, specifics on liver, kidney and pankreas function. Urine may contain microorganisms that indicate kidney damage or diabetes mellitus. Stool may contain bacteria or parasites and indicate digestion anomalies.

15. A CT image of the skull e.g. at the Teaching Hospital of Tribhuvan University costs ca. 2000 Nepali rupees (ca. 25 Euro) as per Nov. 2005; compare the annual per capita income of US $ 235; table see appendix).

16. Hitchcock (1976) writes Jhkri instead of Jhankri

17. Mohan Rai writes Mangpa

18. Jones (1976) writes Phedangma instead of Fedangwa

19. A discussion of possession and spiritual journey as part of the shamanism definition and the pertinent problems of differentiation in Nepal in particular would go beyond the scope of this paper. See Johan Reinhard "Shamanism and Spirit Possession: the Definition Problem" (1976:12ff).

20. The distribution of the rice grains or ginger cubes thrown in a Jokhana (oracle) - if e.g. an even number of ginger cubes shows the side of the cut on top - indicates the type of illness and its prognosis. The shaman thus also decides on the most effective cure for a patient.

21. e.g. through the Phurba (ceremonial dagger), a ritual broom or a Khukuri (Nepalese knife) that are guided along a patient's body downwards in order to remove negative energies (see also Okada 1976).

22. In Naikap, shamans do not sacrifice goats but use animal figures made of fruit, e.g. an animal made of cucumber with wooden sticks as legs.

23. The food offered ritually on a plate made of sal leaves is an invitation to the evil spirit to release the patient and accept the ritual food or a sacrificed animal instead.

24. An estimated 2000 healers practiced ayurveda in Nepal in 1982; of these, about 500 are said to be ayurveda physicians or have qualified e.g. in ayurveda studies. The largest facility for ayurveda treatment in Nepal is the Ayurveda Hospital in Kathmandu.

25. see also previous page "Lamas as healers"

26. a method in Traditional Chinese Medicine (TCM) where moxa or mugwort, e.g. in the form of a moxa cigar, is burnt over the patient's body. This method serves to warm certain body parts in TCM.

27. e.g. hot-cold dichiotomy

28. Field research by Okada (1976), Blustain (1976), Stone (1976) and others indicates that people in rural areas in Nepal tend to consult a shaman or other traditional healer first since these are locally available. But many patients also visit the Health Posts or hospitals, often in addition to a shaman therapy, afterwards or between two such therapy sessions. Ayurveda, Unani or Tibetian medicine and self-treatment with household remedies or over-the-counter medicine are further alternatives to biomedicine and shamanism (Gartoulla 1998).

29. Shamans treat patients for illness due to supernatural causes.

30. Scientific determinism became obsolete a long time ago, and a change in paradigms took place in Western natural science, see research in modern quantum physics. But old patterns with determinism and positivism still seem to dominate biomedical practice in particular. In practice, new findings and concepts, e.g. on mutual influences of body and psyche, gain ground very slowly.

31. Stone (1976:78) says: ,Secondly there have been repercussions from the fact that developing agencies explicitly oppose modern and traditional medicine. Educators instruct school children to abandon their "superstitious" beliefs in illness causation. Doctors deny the validity of local practitioners and encourage patients not to summon them. Local practitioners, in turn, occasionally discourage clients from going to the hospital. With the lines drawn in this fashion, villagers are presented with a new realm of opposing symbols for incorporation into their social life. Of relevance here, villagers in particular contexts seek to be identified with the "modern" world, which, in this area, is largely defined as the world of education. Symbolic denial of traditional medical practices and confirmation of Western medicine is one of the ways in which such identification is effected."

32. Davies (1994/95) quotes Foster (1987): ,the developed world possessed both the talent and capital for helping backward countries to develop"! The idea was to help underdeveloped nations to achieve modern, Western-progressive living conditions.

33. 34 superstitious rural population versus modern urbane population with academic training

34. in addition to the above-mentioned dualism of modern versus backward that dominates society.

35. An extensive discussion of all aspects would go beyond the scope of this paper. Compare Stone (1986): Primary Health Care for whom? Village perspectives from Nepal

36. he may e.g. opt for a nightly healing ceremony with the shaman, or for blood analysis and x-ray and subsequent drug therapy with the physician. There seem to be four core elements that are decisive in both systems: belief, suggestion, group support, and catharsis, according to Peters (1979:35) on Kennedy (1974).

37. In this context the WHO describes the traditional healer as ,a person who is recognized by the community in which he lives as competent to provide health care by using vegetable, animal and mineral substances and certain other methods based on social, cultural and religious background as well as on the knowledge, attitudes and beliefs that are prevalent in the community regarding physical, mental and social well-being and the causation of disease and disability" (WHO 1978:9; in Kristvik 1999:122).

38. See Kristvik (1999:124)

39. See also Green, Edward C.;1988; Can collaborative programs between biomedical and african indigenous health practitioners succeed?

40. "Burning" refers to an intervention where for example burning coals are placed directly on the skin above a point that hurts. Internal pains for example are treated this way (Haddix McKay 2002)

41. see also Poudyal, Bimal (1997): Traditional Healers as Eye Team Members in Nepal

42. see also Allan Young (1983): The relevance of traditional medical cultures to modern primary health care

43. an indication of illness caused by spirits

44. transmission of a disease through droplet infection, smear infection etc.

45. see also Benedikter (2003:240), Molesworth (2006)

46. Dr.med. Wolfgang Starke wrote in an article published in Deutsches Ärzteblatt, August 8 2005, that the United Mission to Nepal (UMN) who built the hospital in Am Pipal ca. 35 years ago, left "in great haste" in 2001. The reasons are still unclear. It was only due to the efforts of former personnel who kept the facility going without being paid for long periods that the hospital survived. I heard repeated hints that maoist intimidation was the reason why the NGO left the hospital.

47. Prof. Dr. Nepal told me in his interview: "But I was surprised, in the western countries like Germany or America, the interest in alternative medicine increased. That again will come back here. That will come back here as well. So there's a doctor in Germany, he does treatment with both the things, he does modern medical treatment also, he does this shamanism also. So Nepali doctors also will start doing that, start practising that. So in a way, it has gone to the West and come back. And the West again is a kind of leader - role models who'll show us the path."

48. See also Poudyal, Bimal: Traditional Healers as Eye Team Members in Nepal